
LIBRARY OF CONGRESS, 



Shelf ..J «*' 



UNITED STATES OF AMERICA. 



MANUAL 



PHYSICAL DIAGNOSIS. 



TYSON 



BY THE SAME AUTHOR. 



GUIDE TO THE EXAMINATION OF URINE. Seventh Edi- 
tion. Just Ready. For the Use of Physicians and Students. 
With a Colored Plate and 42 Illustrations Engraved on Wood. 
Seventh Edition. Completely Revised. i2mo. 255 pages. 
Cloth. $1.50. 

" It is without exception the best work of its kind in the English language." 
— Boston Medical and Surgical Journal . 

" This little work, which has just passed through six editions, has no superior 
in the English language. The subject matter of which it treats is complete 
without being verbose ; it is concise, thorough, and up to date. It is a volume 
that should be in the hands of every medical student, and in the library of every 
practitioner." — Buffalo Medical and Surgical Journal. 

BRIGHT'S DISEASE AND DIABETES. A Treatise on Bright's 
Disease and Diabetes. With Especial Reference to Pathology 
and Therapeutics. With colored plates and many wood engrav- 
ings. 8vo. Price #3.50. 

" Dr. Tyson has presented his subjects so clearly and concisely, and has 
selected his material with such sound judgment, that his work cannot fail to be 
useful to practitioners and students." — The American Journal of the Medical 
Sciences. 

" The symptoms are clearly defined, and the treatment is exceedingly well 
described, so that every one reading the book must be profited." — Cincinnati 
Lancet and Clinic. 

THE CELL DOCTRINE : Its History and Present State, together 
with a copious Bibliography of the Subject. With a colored plate 
and other illustrations. Second revised edition. Cloth. $2.00. 

"The first edition of Dr. Tyson's work appeared in 1870, and at once re- 
ceived the favorable reception from the profession to which it was entitled by 
its merits. The present edition shows an increase in size of about fifty pages, 
and almost every page furnishes evidence of careful revision." — American 
Journal of the Medical Sciences. 



MANUAL 



OF 



PHYSICAL DIAGNOSIS 



FOR THE USE OF 



STUDENTS AND PHYSICIANS. 



JAMES TYSON, M.D., 

PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA 

AND PHYSICIAN TO THE UNIVERSITY HOSPITAL; FELLOW OF THE 

COLLEGE OF PHYSICIANS OF PHILADELPHIA \ MEMBER OF 

THE ASSOCIATION OF AMERICAN^PHYSICIANS, ETC. 



■gl oF _ COA 'Q/ f ^ 




OCT if f#l 



v 




PHILADELPHIA: 
P. BLAKISTON, SON & CO. 

IOI2 WALNUT STREET. 
189I. 



^ ^ 

^ 



Copyright, 1 891, by James Tyson, m. d. 



PRESS OF WM. F. FELL & CO., 

1220-24 SANSOM STREET, 

PHILADELPHIA. 






£b 



PREFACE. 



It cannot be said that the making of a new book on 
Physical Diagnosis is demanded by reason of the few- 
ness of existing treatises on the subject. It is, how- 
ever, but natural that it should occur to one, a part of 
whose duty it is to teach physical diagnosis to large 
classes of medical students, that he might accomplish 
more satisfactorily his task by having a text-book of 
his own preparation. In this I have sought to secure 
conciseness with sufficiency, a task acknowledged to be 
difficult, but which experience in teaching is, perhaps, 
best calculated to overcome. It is the object I especially 
sought in my Manual on the Examination of Urine, 
which has now reached its Seventh Edition. The present 
book is not intended to be pretentious, and if it effects 
its simple purpose in being useful to students I will feel 
repaid. 

1306, Spruce Street, October zst, i8gi. 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Anterior view of the chest and abdominal cavity, .... 13 

2. Posterior view of the chest and abdominal cavity, .... 14 

3. Percussion hammer, 18 

4. Common ivory pleximeter, 18 

5. Sansom's pleximeter, 18 

6. Showing absolute and relative percussion dullness of liver 

and heart, 30 

7. Illustrating Gerhardt's change of note, 38 

8. Hawksley's stethoscope, 43 

9. Robertson's stethoscope, 43 

10. Simple form of double stethoscope, 44 

11. Sansom's double stethoscope, 44 

12. Showing absolute and relative dullness of liver and heart, 91 

13. Showing location of cardiac valves and maximum inten- 

sity, 95 

14. Tracing of pulse of mitral insufficiency, 112 

15. Tracing of pulse of mitral obstruction, 114 

16. Tracing of pulse of aortic obstruction, 116 

17. Tracing of pulse of aortic regurgitation, 118 



VI 



CONTENTS. 



PAGE 

General considerations, 9 

Inspection and mensuration, 15 

Palpation, 16 

Percussion, 18 

Percussion of the normal chest, 27 

Abnormal percussion sounds, 34 

Auscultation, 41 

Auscultation of the normal lung, 45 

Modified normal breathing sounds, 47 

Auscultation of the normal voice, 54 

New or adventitious sounds, 57 

Physical signs of abnormal states of the lungs 62 

Acute bronchitis, 62 

Chronic bronchitis, 5^ 

Emphysema of lungs, 63 

Spasmodic asthma, 65 

Tubercular phthisis, 66 

Catarrhal phthisis, 67 

Fibroid phthisis, 70 

Miliary tuberculosis, 72 

Pneumonia, 72 

croupous, 72 

catarrhal, 76 

embolic, 77 

vii 



Vlll CONTENTS. 

PAGE 

Pulmonary oedema, 78 

Collapse of the lung, 78 

Cancer of the lung, 79 

Pleurisy, 79 

Pneumothorax, 86 

Physical examination of the heart, 88 

Anatomical relations of the heart, 88 

Percussion and auscultation of the normal heart, ... 90 

Abnormal modifications of the heart sounds, 97 

Organic murmurs, 100 

Functional murmurs, 105 

Vascular murmurs, 106 

Physical signs of different forms of valvular disease, .... no 

Mitralinsufficiency, no 

Mitral obstruction, 113 

Mitral insufficiency and obstruction, 115 

Aortic obstruction, 115 

Aortic regurgitation, 117 

Aortic obstruction and regurgitation, 120 

Tricuspid regurgitation, 120 

Tricuspid obstruction, 122 

Pulmonary obstruction, 122 

Pulmonary regurgitation, 123 

Congenital defects, . , 123 

Relative frequency and danger of valvular defects, . . 124 

Endocarditis, , 125 

Pericarditis, 126 

Diseases of the myocardium, 127 

Thoracic aneurism, 131 

Index, 135 



PHYSICAL DIAGNOSIS. 



GENERAL CONSIDERATIONS. 

The term physical diagnosis strictly defined would 
include the diagnosis or investigation of disease by the 
aid of all the special senses, but practically it is con- 
fined to eliciting such information as can be furnished 
by vision, touch, and hearing. Whence come the terms 
inspection, palpation and auscultation. The information 
acquired by hearing is further subdivided — ist. Into 
that gained by listening directly to the normal breathing 
sounds and heart sounds, and to their abnormal modifica- 
tions \ and to certain new sounds produced by diseased 
states. 2d. Information gained by striking or percus- 
sing the part to be investigated. Hence, too, the words 
auscultation and percussion are constantly used in 
association. 

The information furnished by inspection is also ren- 
dered more accurate by measuring or mensuration, when 
this can be applied. Thus constituted, physical diag- 
nosis is applied to any portion of the body, but it is 
more especially in the study of diseases of the thoracic 
and abdominal contents, and particularly the former, 
b 9 



10 PHYSICAL DIAGNOSIS. 

that it is useful. The phenomena thus learned are known 
as physical signs. The use of the term "physical" is 
explained by the fact that it is through alterations in 
the physical properties of the tissue or organ investi- 
gated that information is obtained. On the other hand, 
in its usual application there is a restriction inconsistent 
with strict accuracy. Thus there is no more accurate 
means of recognizing physical states than by thermom- 
etry, yet thermometry is not one of the measures in- 
cluded under the head of physical diagnosis. 

It is very true that physical signs cannot be acquired 
from books and must be learned at the bed-side; but 
we may record their import and significance in the 
recognition of disease and render somewhat easier their 
study. To this end is indispensable a familiarity with 
the physical condition of the organs of the body in a 
state of health. This, too, can only be learned on the 
living subject by giving the student an opportunity to 
listen until he is thoroughly familiar with the normal 
breathing and heart-sounds, to observe the shape and 
configuration of the body, and to learn the percussion 
note characteristic of different regions over important 
organs, as the heart, lungs and various abdominal vis- 
cera. Such a study of the situation of internal organs 
in relation to external parts, for the purposes of the 
physician, constitutes medical anatomy. 

The attainment of the objects of physical diagnosis 
is greatly facilitated by mapping out the chest into cer- 
tain spaces or areas known as the 



REGIONS OR SPACES OF THE CHEST. II 

REGIONS OR SPACES OF THE CHEST. 

The clavicle itself is a useful landmark in physical 
examination, while above each clavicle in health is 
usually a slight depression known as the supra-cla- 
vicular fossa, and above the sternum another known 
as the supra-sternal notch. Below each clavicle 
is the infra-clavicular space, which is somewhat 
arbitrarily bounded below by the upper edge of the 
third rib and adjacent cartilage, internally by the 
edge of the sternum and externally by the base of 
the shoulder or a line drawn vertically from the inner 
end of the outer fourth of the clavicle. Below the 
clavicle, as well as above, in health, is usually a slight 
depression. All these depressions or spaces are liable to 
become deeper from emaciation, and are less conspicuous 
in fat persons. Below the upper edge of the third rib 
is the mammary region, bounded internally by the 
edge of the sternum, externally by the above described 
vertical line, and below by the upper margin of the sixth 
rib. Nearly in the centre of the mammary region is the 
nipple, which in males and young girls is just below the 
fourth rib. A line drawn vertically through it is known 
as the mammillary line. Below the mammary 
region, as far as the edge of the thorax, is the infra- 
mammary region. In the centre of the thorax 
anteriorly is the sternum, bounded by its notch above 
and the end of the ensiform cartilage below. It is 
divided into the upper sternal region, extending as 
far as a line drawn along the upper edge of the third 
rib, and the lower sternal, including the remainder of 



12 PHYSICAL DIAGNOSIS. 

the bone. Laterally are the axillary and the infra- 
axillary regions, separated by a line continuous 
transversely with the lower border of the mammary 
region, and bounded in front by the posterior border 
of the mammary and infra-mammary regions and be- 
hind by a line drawn vertically downward from the 
insertion of the posterior fold of the axilla. The infra- 
axillary region extends below to the edge of the thorax. 

Posteriorly are the supra-spinous fossae of the 
scapulae, the infra-spinous fossae, the interscapu- 
lar region and the sub-scapular or infra-scapular 
regions. The first four are sufficiently indicated by 
their names ; the interscapular region is included be- 
tween the scapulae posteriorly and bounded below by a 
line drawn through the angles of these bones in the po- 
sition assumed by them when the arms are hanging at 
the side. Such line crosses the seventh rib. The infra- 
scapular regions are bounded above by the line just 
described, below by the edge of the thorax, and extend 
from the median line to the posterior axillary line on 
each side. 

In addition to the mammillary line are lines drawn 
vertically down the middle of the axilla and through the 
angle of the scapula behind, called the mid- axillary 
and scapular lines — also landmarks useful in descrip- 
tion. The parasternal line, sometimes used, is a 
vertical line drawn midway between the edge of the 
sternum and the mammillary line. 



Fig. i. 




Anterior view of the Organs of the Chest and Abdominal Cavity with reference 
to their relations to the skeleton and the boundaries of the stomach. 
i. Larynx. 2. Thyroid gland. 3. Trachea. 4. Right lung-apex. 5. Upper 
iobe, 6. Middle lobe, 7. Lower lobe of right lung. 8. Upper, 9. Lower 
interlobular boundary of the right lung. 10. Apex, 11. Upper lobe, 12. Lin- 
gual process of the left lung. 13. Cardiac boundary of the anterior border of 
the left lung. 14. Portion of the anterior aspect of the pericardium covered 
by the cardiac pleura. 15. Portion of same uncovered by diaphragm. Site 
for paracentesis. 16. Anterior border of right mediastinum. 17. Anterior border 
of the left mediastinum. 18. Upper or true border of the liver partially covered 
by lung. 19. Right lobe of the liver. 20. Quadrate lobe of the liver. 21. Left 
lobe of the liver. 22. Gallbladder. 23. Upper end of the stomach. 24. Stomach 
cul du sac partially covered by lung. 25. Pyloric end of stomach. 26. Larger 
curvature of stomach (right gastro-epiploic artery). 27. Transverse colon. — 
After Paul Niemeyer, slightly modified. 



14 



PHYSICAL DIAGNOSIS. 
Fig. 2. 




Posterior View of the Organs of the Chest and Abdominal Cavity, i. Upper 
lobe, 2. Lower lobe of left lung. 3. Interlobular boundary between them. 
6. Middle lobe of the right lung. 7. Line between upper and middle lobes 
of the right lung. 9. Stomach demarked by a dark line. 10. Spleen in its 
relation to the lung in expiration, with the kidney showing behind and below 
it. 11. Left kidney. 12. Horizontal upper part of the duodenum. 13. De- 
scending portion of the duodenum. 14. Horizontal part, lower duodenum. 
15. Duodeno-jejunal flexure. 16. Liver. 17. Pancreas. — After Paul Nie- 
meyer. 



INSPECTION AND MENSURATION. 1 5 

INSPECTION AND MENSURATION. 

The appearances of the regions described, during and 
independent of the motions of breathing, are objects of 
inspection, but these are best described in connection 
with the conditions which modify them. In inspecting 
the chest from the front or behind, the patient should 
stand erect with the hands at the side ; during lateral 
inspection the hands should be raised alongside of the 
head, or they may grasp opposite shoulders. Such rela- 
tions to light should be chosen as will obviate shadows 
as much as possible. It will be remembered that 
during breathing women exhibit more motion in the 
upper part of the chest, while in men abdominal motion 
is marked. 

Mensuration is for the most part practiced by an 
ordinary tape measure, and thus the circumference of 
the chest at different situations is determined; also dif- 
ferences in the circumference at the end of inspiration 
and of expiration, and differences in the semi-circum- 
ference as the result of abnormal states. It is to be 
borne in mind that in right-handed persons the semi- 
circumference of the right side is often half an inch or 
more greater than that of the left, owing to the greater 
muscular development of that side. The reverse obtains 
in left-handed individuals. The transverse diameter of 
the chest may be determined by a pair of calipers ; any 
deviations in the shape of the chest by the cyrtometer, 
a simple form of which may be made out of strips of 
sheet lead, moulded to the chest-walls, and the outline 



1 6 PHYSICAL DIAGNOSIS. 

thus "produced be drawn on a large sheet of paper. 
More perfect appliances for chest measurement are the 
stethometer of Quain, the stetho-goniometer of Allison, 
the cyrtometer of Woillez, and others, but they are not 
needed for the usual measurements. 



PALPATION. 

After inspection and mensuration of the chest, palpa- 
tion is usually practiced. This is done by applying the 
palm of the hand or the fingers, as may best serve the 
purpose, to the chest-wall. The chief value of palpa- 
tion lies in the fact that when the hand is thus closely 
applied, and the person "touched" speaks, a peculiar 
vibrating or trembling sensation is conveyed to the 
hand. This is known as vocal fremitus. This 
fremitus or thrill, representing the vibrations in the 
air below the vocal cords, is communicated to the 
walls of the air passages, from the larger to the smaller, 
until the ultimate structure of the lung is reached, 
whence it is conveyed to the chest-wall and hands. In 
health it is felt everywhere over the chest where lung- 
tissue reaches, but is more distinct where the chest-walls 
are thinnest, and especially in the right infra-clavicular 
space as compared with the left, an important fact to 
be remembered in recognizing delicate shades of differ- 
ence. This is usually explained by the fact that the 
right bronchus is shorter, larger, and enters the lungs 
higher up and more horizontally than the left, whence 
a larger volume of air is contained in the right lung, 



PALPATION. 1 7 

especially in its upper portion, and stronger vibrations 
are produced in speaking. For the same reason tactile 
fremitus is sometimes slightly more distinct posteriorly 
in the right half of the interscapular space, and even 
below the angle of the scapula. In the axilla the same 
difference exists to a less degree. Tactile fremitus is, of 
course, more marked in persons with thin chest-walls 
than in those with thick muscular walls, or walls covered 
with fat, while it is feebler but still easily appreciable in 
women. It is also greatly influenced by the pitch or 
tone of the voice used, being more marked in a deep, 
low-toned speech than in a high one. It is further in- 
fluenced by words selected for utterance. My favorites 
are " ninety-nine," as producing a longer vibration than 
words like "sixty-six," for instance. But "one, two 
three," or "twenty-one," "twenty-two" and "twenty- 
three," and the like, are useful also to bring out vocal 
fremitus. 

Vocal fremitus is increased in abnormal states pro- 
ducing consolidation of the lung, as in pneumonia and 
tubercular deposit, and is diminished by conditions 
which separate the lungs from the chest-wall, as pleuritic 
effusions, and even solid tumors. 

Fremitus is also produced by the action of coughing, 
when it is called tussile, as distinguished from vocal; 
by rales, dry or moist, if the tubes are of sufficient 
calibre, when it is called rhonchal ; also by pleural 
and pericardial frictions. 



i8 



PHYSICAL DIAGNOSIS. 



PERCUSSION. 

Percussion naturally succeeds inspection, and consists 
in striking a part with a view to eliciting sound. In its 
simplest form it is probably as old as medicine, but 
Auenbrugger, of Vienna, was the first to publish, in 
1761, results obtained from its application. Percussion 
is called immediate or mediate, according as the 

Fig. 3. 




E.A.YARNALL CO. PHILA. 

Percussion Hammer or Plexor. 



Fig. 5. 



Fig. 4. 




E - A. YARN ALL CO. PHI L^- 
Ivory Pleximeter. 




Sansom's Pleximeter. 



blow is struck directly upon the part or upon some in- 
terposed medium. Immediate percussion is of limited 
application, but it is still sometimes very useful, and I 
much like to percuss the clavicular region by striking 
directly the bone rather than upon some interposed sub- 
stance. The hammer or agent by which the stroke is 
practiced is the plexor, and the interposed material is 



PERCUSSION. 19 

the pleximeter. By far the most common plexor, 
and for the most part the best, is the middle or index 
finger, or both of these, while one or the other of the 
same fingers of the other hand becomes the pleximeter. 
It is often useful, however, to have a specialized hammer, 
like that figured in the text, while more useful and even 
more indispensable at times becomes a pleximeter, in 
situations which the fingers cannot conveniently reach, 
or where there is much percussing to do, when the 
fingers sometimes become sore and tender, from the 
constant pounding. By far the most satisfactory plexi- 
meter, in my experience, is the little hard-rubber plexi- 
meter suggested by Sansom, and figured in the text. 
Either the larger or smaller end may be applied to the 
chest, and the stroke given to the other side, with equal 
efficiency. 

The pleximeter was invented and first used by Piorry, 
of Paris, in 1828, and the hammer by Wintrich, in 1841. 

The essential conditions of successful percussion are, 
first, the close application of the pleximeter, whether it 
be the finger or an artificial pleximeter, to the chest, so 
that it will form a part, as it were, of the area to be 
percussed ; and, as the two sides of the thorax are com- 
monly compared, precisely corresponding points should 
be selected. Then care should be taken to strike with 
equal force on each side. When the fingers are used as 
plexors, the stroke should be made from the wrist, and 
vertically on the pleximeter, while the hand should be 
raised quickly, and one, two, three or more blows given 
until the proper sound of the part is elicited. To this 



20 PHYSICAL DIAGNOSIS. 

end the stroke should be neither too forcible nor too 
feeble. When the proper note is brought out it should 
be remembered and compared with the sound elicited 
under the same conditions at the corresponding point 
on the opposite side. Practice with attention to these 
conditions can alone make perfect. 

The sound produced by percussing the chest is a 
mixed one, made up of the vibrations of the pleximeter, 
those of the thoracic wall and those of the air in the 
lungs. The first, when the finger is used as a pleximeter, 
is scarcely noticeable, but when a pleximeter of ivory 
or hard rubber is used this element may be recognized, 
especially when the pleximeter is accidentally struck by 
the nails of the finger used as plexor. In like manner 
the vibrations of the thoracic wall are insignificant and 
unnoticeable under ordinary circumstances, in com- 
parison with the vibrations of the air in the lungs, which 
are responsible for most of the sound produced in per- 
cussing the normal chest. These vibrations are set up 
by the blow, and it is the sound thus produced, variously 
modified in health and disease, which we are to study. 

Auscultatory percussion is a term applied to a 
method introduced by Cammann and Clark, which con- 
sists in listening, with a stethoscope applied to the chest- 
walls, to the sounds obtained by percussion. 

Respiratory percussion is a term proposed by 
DaCosta for the study of a note made by percussion 
while the breath of a patient is held, after a deep in- 
spiration or after a prolonged expiration. Constant ref- 
erence will be made to the effect of the latter on sounds 
elicited by percussing normal organs. 



PERCUSSION. 21 

ATTRIBUTES OF PERCUSSION SOUNDS. 

Percussion sounds have attributes of quality, in- 
tensity or loudness, pitch and duration. None of 
these attributes can, strictly speaking, be so described 
as to enable it to be recognized by the ear. Practice 
and illustration must be associated with the description 
in order that an adequate idea may be obtained. 

Quality is the easiest indicated of the attributes of 
sound. Although Flint correctly says of it that " to 
attempt to describe the quality of sounds to one who 
has never heard them would be like describing colors 
to one who is blind/' illustration happily comes to our 
assistance and helps greatly. Thus it is not difficult for 
any one who has heard it to recognize the note of a 
violin or piano and to name the instrument producing 
it. The attribute by which such recognition is made 
is quality of sound, and each quality is produced by 
certain conditions peculiar to the instrument producing 
the sound. It varies therefore with those conditions. 

Now the qualities of sound produced by percussing 
the normal chest are' mainly two: ist, the normal 
vesicular resonance or clear sound ; 2d, the dull sound 
or dullness. A third quality, not strictly speaking a 
normal thoracic sound, but so conspicuous in adjacent 
organs in health as to often influence the thoracic 
sounds, will also be described in this connection. I 
allude to tympany. Each of these is produced by con- 
ditions peculiar to itself. 

The term vesicular resonance or clearness as ap- 
plied to the healthy chest is produced by percussion 



22 PHYSICAL DIAGNOSIS. 

over a structure containing air in minutely divided 
spaces. Such structure is its condition, and the sound 
produced is as much sui generis as is the violin's sound. 
It is of the nature of a reverberation and is reverbera- 
tion modified by minute subdivision of air spaces. It is 
not inaptly compared by Flint to the sound produced 
by percussing a loaf of bread over which a towel has 
been spread, the upper crust of the bread corresponding 
to the chest-wall ; but, as a rule, normal resonance is 
characterized by less hollowness than the percussion of 
a loaf of bread. It differs in different parts of the chest 
of the same individual, and in different individuals. 
Its typical quality may be found in either infra-clavicu- 
lar space or below the angle of either scapula in persons 
with chest-walls of moderate thickness. 

The chief cause which operates to produce the dif- 
ferences alluded to is the varying thickness of the chest- 
walls; but the state of tension of the air in the air vesicles 
has also to do with it, as has also the position of adjacent 
viscera and the mode of percussion, according as it is 
forcibly or lightly practiced, according as it is well or 
faultily done. These differences are the direct result 
of the changes in the other three attributes named, 
intensity, pitch and duration. 

Intensity means simply loudness and increases pari 
passu with the thinness of the chest-wall and the force 
of the percussion blow. The effect of the attributes of 
pitch and duration are best studied after the other quali- 
ties mentioned, dullness and tympany, are considered. 

Dullness in general may be defined as diminished 



PERCUSSION. 23 

resonance, but the term is not used by all authors with 
a single meaning. Thus DaCosta says,* " a. dull sound 
denotes the absence of air. It is the sound both of 
fluids and solids. It is, thus, the sound sent forth by 
the airless viscera ; from the liver, spleen and heart." 
Others, however, as A. Flint, Sr., E. T. Bruen, F. C. 
Shattuck, would. use the term " flatness " to indicate this 
condition, exhibiting its typical note in percussing the 
thigh. R. C. M. Pagef applies the term flatness to the 
quality obtained by percussing over fluids contained in 
thin walls, and presumably also, over pure solids. To 
retain the word flatness for the sound produced by per- 
cussing an absolutely airless organ or fluid, and dullness 
for resonance diminished in positive degree, gives a de- 
sirable latitude in the use of terms, further increased by 
the application of the adjective terms slight, moderate, 
considerable or marked. I shall therefore use the term 
in this sense. Dullness and flatness are both associated 
with increased resistance to the percussing finger, a sign 
also more or less valuable in diagnosis. 

Tympany or tympanitic resonance is the sound 
elicited by percussing over a large cavity filled with 
air — a cavity whose walls are rather thin, and neither 
very tense nor very yielding. The stomach and intes- 
tines furnish such a cavity, and it is in this region that 
we seek the tympanitic quality of resonance. Tympany 
also has variations due to the size of cavities and to pitch, 

*" Medical Diagnosis," 7th ed. ; 1890, p. 264. 
f " Physical Diagnosis," 3d ed. ; p. 23. 



24 PHYSICAL DIAGNOSIS. 

which will be better understood after this attribute of 
sound is considered. 

We are now ready to discuss and illustrate the attri- 
butes of pitch and duration, neither of which are so 
easily described as quality and intensity. They can in- 
deed only be learned by practice and with varying 
facility by different ears, the musical ear having a deci- 
ded advantage. Perseverance, however, will enable any 
one to appreciate them sufficiently for practical pur- 
poses. 

First as to pitch. We speak of it as high or low and 
of intermediate degree. Pitch is higher the more rapid 
is the succession of the vibrations of the sounding body 
and of the sound waves which emanate from it, while 
intensity depends on the amplitude or extent of these 
waves. Shrillness is the acme of pitch, loudness of 
intensity. The higher the tension of a percussed cavity 
containing air the more numerous the vibrations and the 
higher the pitch, but the shorter the vibrations and the 
less the intensity. Vice versa, a high pitched tympanitic 
resonance would indicate a smaller cavity with tenser 
walls than low pitched tympany. The normal vesicular 
resonance is characterized by its low pitch, because the air 
vesicles, from their elasticity, are not in a state of high 
tension. If, however, the lungs be forcibly dilated, the 
air vesicles are placed in a state of higher tension and 
of diminished elasticity, a situation akin to that of a 
distended stomach, and if percussion be now practiced 
over such areas the pitch will be raised, but there will 
be added not only a higher pitch, but also a tympanitic 



PERCUSSION. 25 

quality, and a note will be produced which was named by 
the late Dr. Flint vesiculotympanitic resonance. 
It is a mixed note, therefore, and its conditions are pro- 
duced by any cause which over-distends the air vesicles, 
as prolonged crying in a child. It is also the note of 
the over-distended air vesicles in emphysema of the lung 
or of portions of a lung, supplementally active in conse- 
quence of impairment of function in other parts. A 
tendency to vesiculotympanitic resonance also exists at 
the right apex of the lung as compared with other situa- 
tions of typical resonance, and is recognized by the 
shadowy higher pitch sometimes noticeable in that 
locality. Tympanitic sounds, although generally high 
pitched, also vary in pitch, the latter increasing inversely 
as the size of the cavity and directly with the degree of 
tension. Thus the stomach being a large cavity gives 
on percussion a lower pitch than the small intestine 
distended to an equal degree. On the other hand, 
tension may be made so great by forcible distention, 
say of the stomach, that the tympanitic sound may be 
destroyed. In the moderate distention which gives us 
good tympany, the stomach wall is not tense enough to 
be thrown into vibrations, the air within the cavity alone 
vibrates and true tympany results. If, however, the 
distention is excessive, percussion throws both walls 
and contained air into vibration, and the two sets of 
vibrations interfering with each other a non-tympanitic 
muffled sound results. If, again, the walls of a cavity 
are so firm that they cannot vibrate at all, a modified 
tympany results which is called amphoric, to be again 
c 



26 PHYSICAL DIAGNOSIS. 

referred to. Indeed, the stomach note obtained on 
percussion is often rather more amphoric than tym- 
panitic. 

Dull and flat percussion are high pitched in their 
note, and the pitch increases with the dullness and the 
area of the dullness, while the first suggestion of im- 
paired resonance is a slight heightening of pitch which 
the practiced ear readily recognizes, and attaches to it 
great importance. The tendency to higher pitched 
note just below the right clavicle as compared to the left 
is also to be remembered in weighing slight differences in 
the percussion note of the two sides. It is associated 
with the tendency to increased vocal fremitus in the 
same situation, already referred to. 

The explanations of this tendency to slightly higher 
pitched resonance and slight dullness at the right apex 
are not uniform, and are therefore best considered in a 
foot-note.* 

* First is the explanation of Flint, who, in ascribing it to a special 
character of vesiculo-tympany, implies some change in the elasticity 
of the air-vesicles. How this is brought about except by some 
greater functional activity of the right apex I do not know. 

The second explanation of this slight impairment of the resonance 
is based on the different arrangement of the bronchial tubes on the 
right side as compared with the left. The former are larger, extend 
higher up than the latter, and thus give us more tubular tissue, in- 
cluding a larger proportion of connective and muscular tissue to deal 
with in percussing, which would give us slightly less resonance. 

A third explanation, which certainly must be allowed to apply in 
some instances, is the greater muscular development of the right 
side of the body, and in consequence greater thickness of the pec- 



PERCUSSION OF THE NORMAL CHEST. 27 

Duration is the attribute of least importance. It 
varies inversely with the pitch, that is, the higher the 
pitch the shorter the duration, and vice versa. 

We are now ready to study the percussion sounds as 
heard in the different regions of the chest as already 
mapped out. 

PERCUSSION OF THE NORMAL CHEST. 

First, in the supra- clavicular spaces. 

Satisfactory percussion here is difficult and results are 
not to be too much relied upon. The nearest approach 
to normal clear percussion or vesicular resonance is 
found above the centre of the clavicles where the lungs 
rise from half an inch to an inch and a half or even two 
inches above the clavicle, being usually higher in women 
than in men. Towards the inner end of the clavicle 
the percussion may acquire a more tympanitic quality, 
on account of the proximity of the trachea, while towards 
the outer end a duller note obtains. 

On the clavicles themselves percussion is clear, 
almost typically so, over the middle of the bone, but 

toral muscles of that side. This would also cause a slightly higher 
pitch. The opposite state of affairs in left-handed persons would 
go far to confirm this, but I am not aware of any systematic observa- 
tions intended to settle this question. 

Still another explanation of this difference is based on the fact 
that the right lung rests, through' the diaphragm, upon the right lobe 
of the liver, which is a dense organ, and percussion of the lung 
would be modified, by such relation, towards a slight impairment of 
resonance. It is not impossible that any one or more of the first 
three causes might operate to produce the difference on the two sides. 



28 PHYSICAL DIAGNOSIS. 

becomes duller as the outer end is approached, while 
on the inner end it may be higher pitched. 

The infra-clavicular spaces furnish in health the 
typical clear percussion-note or vesicular resonance as 
far as the upper edge of the fourth rib \ on the right 
side is to be looked for the shadowy higher pitch, the 
vesiculo-tympany of Flint, so that Page selects the left 
subclavicular as the typically normal. This difference 
is not invariable, but the fact is to be remembered in 
weighing shades of difference with a view to diagnosis. 

In the mammary region percussing down the right 
mammillary line, the clearness continues, possibly a trifle 
less on account of the greater thickness of the pectoral 
muscle until the fourth interspace or the fifth rib is 
reached, when there is a raised pitch and diminished 
intensity which passes at the sixth interspace or seventh 
rib into a positive dullness, which continues in health 
to the edge of the ribs. This impairment of the reso- 
nance on the right side is due to the liver, the lesser 
degree being known as the deep or relative dullness, 
and below this the absolute dullness. The upper border 
of the absolute dullness corresponds with the lower edge 
of the right lung. Close to the sternum on the right 
side there may be slight impairment of resonance, due 
to the relative dullness of the right auricle and ventricle, 
beginning with the third rib and passing at the fifth into 
the relative dullness of the liver, and at the sixth into 
the flatness of that organ. On forced inspiration the 
liver is pushed downward an inch or more, and on 
forced expiration there is a corresponding rise. 



PERCUSSION OF THE NORMAL CHEST. 29 

On the left side, close to the sternum," normal vesicular 
resonance begins to lessen at the third interspace, owing 
to the deep or relative dullness of the heart, and at the 
fourth costal cartilage is replaced by the absolute dull- 
ness of this organ, which continues down along the 
left edge of the sternum until it passes into the left lobe 
of the liver, from which it cannot be demarked ; but in 
general terms the cardiac dullness may be said to extend 
from the fourth to the sixth rib, and from the sternum 
to a curved line extending a short distance along the 
fourth cartilage and thence down within the nipple line 
to the seat of the apex beat. The cardiac area of dull- 
ness is also diminished on deep inspiration, because the 
organ becomes more fully covered by the distended 
lungs. Without the nipple in both sides there is, in 
health, resonance to the anterior axillary line, slightly 
lessened by the mammary gland and pectoral muscle. 

The infra-mammary or hypochondriac region 
on the right side is wholly occupied by the liver and 
furnishes flat percussion. The width of the area of 
absolute dullness of the liver is about three inches. On 
the left side the percussion in this region varies greatly 
in different persons and in the same person at different 
times. Towards the sternum the left lobe of the liver 
for the most part maintains its dullness, but even this is 
sometimes replaced by the tympany of a dilated stomach, 
while to the outside of this, the stomach as normally 
distended with gases quite frequently imparts a tym- 
panitic note. On the other hand the presence of solids 
and fluids in the stomach in varying amounts contributes 



Fig. 6. 




Showing Absolute and Relative Percussion Dullness of Liver and Heart. 



PERCUSSION OF THE NORMAL CHEST. 3 1 

dullness. A spleen of normal size does not extend into 
the infra-mammary region. In this connection it may- 
be said that the lower edge of the liver generally corre- 
sponds to a line drawn from the sixth rib within the 
left mammillary line obliquely across the epigastrium 
to the junction of the right mammillary line with the 
edge of the thorax. 

In the supra-sternal notch, also difficult to percuss, 
tracheal tympany may be brought out by vertical percus- 
sion on a suitably placed pleximeter. Over the upper 
sternal region, as far as the third rib, the percussion is 
resonant, with a slightly tympanitic note communicated 
by the trachea. Below this for a short distance there is a 
purer lung note. At the fourth rib the heart, though 
covered in by the lungs, begins to deaden the note, but 
it is still clear until the liver is reached at the sixth 
rib, where dullness is absolute and extends in the median 
line half way to the umbilicus, although a tympanitic 
stomach may also influence this. 

In the axillary spaces on both sides there is good 
pulmonary resonance. In the infra-axillary of the right 
side, the relative dullness of the liver is noted at the 
seventh rib on the mid-axillary line and the absolute 
dullness at the eighth, but sometimes at the ninth. On 
the left side there is also clearness until the spleen is 
reached in the mid-axillary line at the seventh rib, whence 
it extends to the ninth. . Laterally the spleen extends 
upwards and backwards between these two ribs from two 
to three inches, and sometimes it is so covered in as to 
escape careful percussion. The left infra-axillary region 



32 PHYSICAL DIAGNOSIS. 

is also apt to be encroached upon by the tympany of 
the stomach. 

Posteriorly. Percussion is best practiced with the 
patient leaning slightly forward and folding his arms. 
The upper border of the lungs behind is on a level with 
the spinous process of the seventh cervical vertebra. 

In the supra-spinous fossa the percussion resonance 
is markedly less than the typical, because of the bone and 
the thick muscles overlying it, and the same may be said 
of the infra-spinous region. At the same time percus- 
sion here is important because differences on the two 
sides are usually easily recognizable. 

In the interscapular region there is again better 
resonance than over the scapulae themselves, but still 
less intense than below the angles of the scapulae, on 
account of the tolerably thick muscles and the spinal 
column. In the upper portion the tympany of the 
trachea may influence the note. 

In the infra-scapular regions we have the nearest 
approach behind to the typical resonance as represented 
by the left infra-clavicular space. The information 
obtained here by percussion is most valuable, only 
second in importance to that obtained by percussing 
below the clavicles, and in consequence of this it is 
important to remember the inferior border of the 
normal resonance. The lower border of the lung on 
both sides corresponds to the tenth rib, where, on the 
right side, the absolute dullness of the liver is found, 
while the relative dullness on strong percussion is found 
a rib higher. On the left side resonance extends in the 



PERCUSSION OF THE NORMAL CHEST. 33 

line of the angle of the scapula fully to the tenth rib, 
though sometimes a tympanitic quality may be imparted 
by a dilated stomach or the colon, or a slightly dull 
sound if the spleen extends a little farther back than 
usual. Here as elsewhere on the thorax there may be 
slightly less intensity, and slightly higher pitch on the 
right side, on account of the greater muscular develop- 
ment in right-handed persons, and the effect of a deep 
inspiration on lowering the resonance, and in expiration 
of raising it an inch or more, is also to be remembered. 
In ordinary breathing the normal resonance posteriorly 
passes at the tenth rib into the absolute flatness of the 
lumbar region. 

The upper border of the kidneys under the eleventh 
rib, the left being a little higher than the right, cannot 
ordinarily be separated by percussion from the dullness 
of the spleen and liver, nor can the inner border be 
separated from the spinal column. The outer edge can, 
however, be defined, by percussion, from the colon on 
the right and the stomach on the left, by percussing out- 
wards from the median line behind. The outer border 
of the kidney is about three or four inches beyond the 
median line. The lower border can sometimes be de- 
fined by a line of tympany just above the crest of the 
ilium. Forcible percussion is required, and it is desir- 
able to place a pillow under the abdomen of the patient 
lying prone upon his face. 



34 PHYSICAL DIAGNOSIS. 

ABNORMAL PERCUSSION LUNG SOUNDS. 

It goes without saying that a sound which is normal 
in one situation becomes abnormal when heard in a 
position unnatural to it in health, as dullness or tympany 
below the clavicles or below the angles of the scapulae, 
where vesicular resonance is ordinarily heard. But in 
addition there are certain positive modifications of 
normal sounds not heard anywhere in health, or at least 
under such exceptional conditions as do not permit 
them to be included among normal sounds. 

These are vesiculotympanitic resonance, am- 
phoric resonance, and cracked-pot sound. 

Vesiculo-tympanitic Resonance. — The vesi- 
culotympanitic resonance of Flint has already been 
alluded to, but requires to be further considered because 
it is not generally recognized by either American, 
English or German authors, as something distinct and 
different from tympany, and it requires to be con- 
formed to their treatment of conditions supposed to cause 
it. In the language of its describer " the resonance 
increased in intensity; the quality a combination of the 
vesicular with a tympanitic, and the pitch higher in 
proportion as the tympanitic quality predominates over 
the vesicular." According to him also the morbid 
condition which especially illustrates this form of reso- 
nance is the over-dilatation of the air vesicles which 
constitutes vesicular emphysema of the lungs, but it is 
also present in interstitial or interlobular emphysema. 
Also, over the upper lobe of a lung when the lower lobe 
is solidified in the second stage of pneumonia, and over 



ABNORMAL PERCUSSION LUNG SOUNDS. 35 

the lower lobe when the upper is solidified. So, also, 
if the lower part of a pleural sac contains fluid,, even 
though the volume of the lung is diminished, the upper 
part of the same lung may give the same vesiculo- 
tympanitic note.* Too much of the intra-thoracic space 
must not be occupied, as the lung is thus compressed 
and rendered airless, but the resonance is vesiculo- 
tympanitic above the liquid when the latter is sufficient 
to fill a third, a half or even two-thirds of the intra- 
thoracic space. 

Now these are essentially the conditions named by 
Da Costa, Paul Niemeyer and Graham Brown as pro- 
ducing tympanitic resonance of lung tissue. Says Brown, 7 
" just as when the lung is removed from the body and 
allowed to collapse it gives a tympanitic note, so when 
a similar retraction and relaxation of the pulmonic tissue 
takes place within the thorax, that variety of percussion 
note may be heard. This is best marked in cases of 
pleuritic effusion which, gravitating to the lower portion 
of the cavity, floats up the lung and causes relaxation 
of the upper portion. When the effusion is small in 
amount the tympanitic note can only be detected over 
that portion of the lung which lies immediately above 
the upper limit of the fluid, but when the effusion is 
considerable the whole upper lobe may be tympanitic 
on percussion. Similarly, effusion into the alveoli in 

* This is what is known as Skoda's sign. 

f"Medical Diagnosis", 3d edition, Edinburgh, 1887, page 207. 



36 PHYSICAL DIAGNOSIS. 

pneumonia or oedema may produce a like result."* 
Niemeyerf adds, occasionally gangrene and infarct, 
also disseminated tubercular infiltration, emphysema 
and nervous asthma, and that portion of the lung not 
inflamed but immediately adjacent to a hepatized part. 
In like manner phthisical consolidations of the apices 
may also occasion an obscurely tympanitic note over 
neighboring portions of the lung. Finally, Da Costa, 
who with Flint may be regarded as representing the 
American School, says, " but generally a tympanitic 
sound over the seat of the lungs is expressive of emphy- 
sema or of pneumothorax, or sometimes of a cavity or 
of oedema of the lungs. Again, as Skoda has taught us, 
it occurs in moderate pleuritic effusions above the level 
of the liquid. "J 

It has seemed to me important to contrast these state- 
ments, both in order to give a better idea of what Flint 
intends to convey by vesiculo-tympanitic resonance and 
to avoid confusion in the minds of those who might with 
reason be confused by statements apparently so diverse. 
That there should be something different from typical 
tympany in the percussion note produced under the 
circumstances named seems likely, yet I am by no means 

*This can occur only in the first and third stages of pneumonia 
when the air vesicles contain air, the second stage being one of 
absolute airlessness and dullness. 

f Grundriss der Percussion und Auscultation. Zweite Auflage. 
Erlangen, 1873, pages, 38, 39. 

% " Medical Diagnosis," 7th edition, 1890, page 265. 



ABNORMAL PERCUSSION LUNG SOUNDS. 37 

certain that the words exaggerated resonance or hyper- 
resonance would not convey the idea sufficiently well. 

Pure Tympanitic Resonance. — Tympanitic re- 
sonance is found in normal thoracic states only over the 
larynx and trachea and in the left infra-axillary region 
from encroachment of a tympanitic stomach. Elsewhere 
it becomes a sign of an abnormal state. 

In the chest, tympany is produced first in percussing 
over air-containing cavities in the lung tissue, sufficiently 
near the surface and sufficiently large, and whose walls 
are not too tense. As these cavities usually communicate 
with a bronchus they are further characterized by differ- 
ences in the pitch when percussed with the mouth open 
or closed. This is Wintrich's change of note, according 
to which percussion over a given cavity gives a higher- 
pitched tympanitic sound with the mouth open than 
when it is closed. This may be illustrated by percussing 
over the thyroid cartilage under the two conditions, 
when the difference will be very evident. It occurs in 
connection with superficially placed cavities in com- 
munication with a bronchus. If this change of sound 
is observed on lying down, but is not on sitting up, or 
vice versa, it means that the bronchus leading to the 
cavity is obstructed in the position in which the Win- 
trich change of note does not occur. This is the 
interrupted change of note of Wintrich. 

Approximate estimates as to size and shape of cavities 
may be even made by observations as to pitch. Thus a 
cavity of small size will give a higher-pitched tympa- 
nitic note than one of a large size. Through Gerhardt's 



38 



PHYSICAL DIAGNOSIS. 



change of note we learn something about the shape of 
cavities. Cavities which have unequal diameters, or are 
oval in shape and are partially filled with fluid, alter 
their note on changing the position of the patient from 
sitting to horizontal. Thus suppose A to represent an 
oval cavity in the vertical position with the contained 



Fig. 





To illustrate Gerhardt's change of note. 



fluid at the line c d. If the patient lies down the long 
diameter will become horizontal as in B and the level of 
the fluid will fall to a b. The percussion note is lower 
when the longer diameter is horizontal, higher when it 
is vertical. If, therefore, the percussion note is lower 
when the patient is sitting up, the direction of the longer 



ABNORMAL PERCUSSION LUNG SOUNDS. 39 

diameter is antero-posterior ; if it is higher while sitting 
up the long diameter is vertical. 

Every cavity does not, of course, furnish the condi- 
tions of tympanitic percussion. 

Second, pure, tympanitic resonance is also character- 
istic of pneumothorax if the distention is not too great. 
There being no communication of such a space with a 
bronchial tube, no change of pitch is produced on open- 
ing and closing the mouth, but if there happens to be 
liquid in the sac, Biermer's change of note may be pro- 
duced as follows : In the vertical position of a pneumo- 
thorax containing fluid the cavity is larger because the 
weight of the fluid pushes the diaphragm downwards. 
Hence in this position the pitch is lower. If the posi- 
tion of the patient is now changed from the vertical to 
the horizontal the cavity becomes smaller by reason of 
the changed position of the fluid and the pitch becomes 
higher. 

Third, a pure tympanitic resonance may be produced 
in pneumonia and pleurisy, when the hepatization is so 
complete or the pleuritic exudation in such close relation 
with the lung that percussion throws into vibration the 
air in the trachea and bronchi. 

Amphoric Resonance. — Amphoric resonance, a 
variety of tympanitic resonance, is a high-pitched metallic 
resonance, so called from its resemblance to the sound 
produced by striking the side of a jar, either empty or 
containing a small quantity of fluid. It may also be imi- 
tated by filliping the cheeks when the mouth is dis- 
tended with air. It is an echoing sound, the waves 



40 PHYSICAL DIAGNOSIS. 

being reflected from side to side of the closed vessel, as 
speech in a vaulted chamber. Amphoric resonance is 
said to be produced or intensified by what is known as the 
bell-metal test of Gairdner, in which a coin of sufficient 
size is percussed by means of another on the anterior 
surface of the chest, while the auscultator listens pos- 
teriorly. 

The conditions of its production in the human body 
are an air-filled cavity of considerable size with firm 
and smooth walls, completely closed or communicating 
with the air by a small opening only. These condi- 
tions are fulfilled by certain phthisical cavities, and 
especially by pneumothorax or pyopneumothorax. If 
with such a pyopneumothorax the body be shaken, the 
splashing or succussion will somehow have the same 
ringing character. 

The Cracked-pot Sound. — This sound is well- 
named because it quite resembles that produced by tap- 
ping a cracked jar, and is therefore one of the most dis- 
tinctive and easily recognized of the abnormal percus- 
sion sounds. It is, too, a modification of tympany, and 
is caused by the sudden expulsion of air from a cavity 
through a small opening by a sudden forcible blow. It 
is also imitated in mechanism as well as character by 
suddenly striking the back of the two palm-apposed 
hands against the knee, after the method used by the 
boys to imitate the clinking of coins. 

It may also be made by striking the pleximeter when 
the latter is not closely applied to the skin, an accident 
favored by a hairy skin. The cracked-pot sound may 



ABNORMAL PERCUSSION LUNG SOUNDS. 41 

also be produced in the normal chest by percussing it 
sharply while the patient is in the act of speaking or 
crying out, the narrow glottis affording the condition of 
a small opening. This may more readily be done under 
these conditions in children who have thin elastic chest 
walls. 

The cracked-pot sound is produced in disease by per- 
cussing over a cavity which affords the condition named, 
viz., a somewhat superficial position, sufficiently yielding 
walls and communicating by a small opening with a bron- 
chial tube and thence with the outside air. It is the 
most infallible sign of a cavity known. In producing 
it, the mouth of the patient is kept open and a sudden 
forcible blow of the plexor given. Often it cannot be 
heard unless the ear is attentively turned near the chest 
to catch the sound. The same conditions exist in a 
pneumothorax, with a thoracic fistula into the lung, and 
under these circumstances a cracked-pot sound may be 
produced. 



AUSCULTATION. 

Auscultation is the act of listening to sounds, more 
particularly those produced in the chest in the act of 
breathing or in the course of the heart's action, or in the 
blood-vessels, or to these sounds as modified by disease. 
In so doing the ear is applied either directly to the 
chest or through the intermediation of an instrument 
known as a stethoscope. According as this instrument 
is employed or not, the auscultation is mediate or 

D 



42 PHYSICAL DIAGNOSIS. 

immediate. Both have their advantages. When it is 
desired to isolate or circumscribe a sound, especially in 
the study of the heart, the stethoscope helps us greatly, 
while in the study of more diffuse sounds, as many of 
those produced in the lungs, the direct application ot 
the ear to the chest is generally to be preferred. The 
stethoscope becomes also desirable in the examination 
of patients not especially clean. In inexperienced 
hands, also, the patient is rendered uncomfortable by 
undue pressure with the head on the instrument. 

The stethoscope was invented and used by Laennec, 
of Paris, in 1816, in its single shape. The binaural in- 
strument was devised by Cammann, of New York city, 
in 1840. There can be no doubt that, with the latter, 
sounds are more loudly heard. On the other hand, all 
noises, as that of the rubbing of linen or clothing, are 
so much exaggerated that the beginner is often confused. 
The double instrument is becoming more popular of 
late, but preference depends on training. A man who 
has been brought up to use the double stethoscope soon 
grows to prefer it, while he who is trained to the single 
instrument would not have the double. When either 
form of the instrument is used, better results are ob- 
tained when the chest-end is applied directly to the bare 
skin, whereas in immediate auscultation it is desirable 
that there should be a thin, soft towel, or some thin gar- 
ment, interposed between the ear and the skin. The 
ear or stethoscope should also be applied closely to the 
chest-wall so as to become a part of it or continuous 
with it ; and yet, as stated, the . stethoscope may be 



AUSCULTATION. 



43 



applied too strongly, so as to give pain to the patient. 
Successful auscultation requires that the attention should 
be closely concentrated on the matter in hand. 
. The single stethoscope is made of wood or metal. 
That originally made by Hawksley, of London, out of 



Fig. 8. 





Fig. 9. 




Hawksley's Stethoscope. 



Robertson's New Stethoscope. 



gun- metal, provided with a detachable ear-piece, shown 
in figure 8, is the most convenient and neatest. The 
double instrument, figure 10 in the text is partly metal 
and partly rubber tubing. The very simple instrument 



44 



PHYSICAL DIAGNOSIS. 



of Sansom, of plain rubber tubing and a metallic tube 
end is much more conveniently carried. It is especially 
convenient when the patient is inaccessibly placed in 



Fig. jo. 




Simple Form of Double Stethoscope. 

relation to the examiner, an advantage possessed in va- 
rious degrees by all binaural stethoscopes over the single 

Fig. ii. 




Sansom's Double Stethoscope. 



instrument. In selecting a Sansom's stethoscope, care 
should be taken to secure an ear-piece which fits the ear 
properly. Fig. 9 represents a new stethoscope devised 



AUSCULTATION OF THE NORMAL LUNG. 45 

by Mr. W. E. Robertson, student of medicine, and 
made by E. A. Yarnall Co., in which the ear-piece is 
flexible rubber, which permits it to be closely applied 
to the inequalities of the ear, thus securing greater 
efficiency and greater comfort. The chest-piece has a 
soft rubber end secured to the metallic cone, which is at 
once more closely adherent to the part auscultated, and 
is also more comfortable to the patient against whom it 
is pressed. 

AUSCULTATION OF THE NORMAL LUNG. 

The breathing sounds in health are separable into two 
distinct orders : first, the vesicular breathing or 
respiratory murmur ; second, bronchial breath- 
ing. Both are normal sounds, constantly produced in 
the act of breathing, but in certain parts of the chest 
one is produced more or less to the exclusion of the 
other. Thus the vesicular breathing is heard in its most 
typical character under the left clavicle, where it is best 
studied by immediate auscultation. 

Bronchial respiration is the easier of description. 
It is blowing or tubal in quality, both in inspiration and 
expiration, and the two parts are nearly equal in length, 
the expiratory being often slightly the longer. It is 
heard in its purest form over the larynx and trachea, but 
also quite pronouncedly between the scapulae at the root 
of the lungs, where, however, it is more or less admixed 
with vesicular breathing. The pitch is high in both 
in- and out-breathing, and somewhat higher in the 
latter. 



46 PHYSICAL DIAGNOSIS. 

Vesicular breathing is the sound produced by the 
movement of the air in the smallest bronchial tubes and 
air vesicles. It is also divided into two portions — the 
inspiratory and expiratory, the in- and out-murmur, 
the former being much the longer. Perhaps no language 
can give a correct notion of the vesicular murmur, but 
it is a soft, low-pitched sound, said to resemble the 
sighing of a gentle breeze through the leaves of a tree. 
It is the sound of the movement of the air in the finest 
bronchial tubes and air vesicles. As stated, when typi- 
cal, the inspiratory murmur is much longer than the 
expiratory. The ratio is, however, not fixed. The 
expiration may be one-fourth as long, or it may be a 
mere whiff, as it were. It represents the recoil of the 
air vesicles and the backward movement of the air. The 
precise mechanism of the productions of the sound in 
question will be left to the physiologist, the present 
purpose being to consider the sound and its modifica- 
tions in disease. 

The vesicular murmur is not everywhere the same, 
even in health. As a rule it is loudest, most intense, 
below the left clavicle, and, assuming it to be typical in 
this situation, is nearest maintained in the axillae and 
below the scapulae. Under the right clavicle the 
slightest rise in pitch and a distinct prolongation of 
the expiratory portion is often noted, and to be remem- 
bered as of great importance in diagnosis, in doubtful 
cases. This is usually ascribed to an admixture of the 
bronchial element due to the larger size of the right 
bronchus, and of its branches sent up towards the right 



AUSCULTATION OF THE NORMAL LUNG. 47 

clavicle. Over the scapular regions posteriorly the 
vesicular murmur is less intense, because of the thick- 
ness of the bones and muscles, but the same difference 
between the two sides may often be noted in the supra- 
spinous fossae as below the clavicle in front. For the 
same reason it is less intense in the mammary regions, 
and in all fat and muscular persons as compared with 
the thin and emaciated. Between the angles of the 
scapulae still more of the bronchial element is added 
than below the right clavicle, and the sound is decidedly 
more blowing and the expiration longer. It is to be 
remembered that both vesicular and bronchial breathing 
are being constantly produced in the lungs, but that in 
certain situations one overshadows the other, partly 
because it is being produced in greater degree immedi- 
ately under the point where the ear is applied, and 
partly because the normal lung is a poor conductor 
of sounds. 

MODIFICATIONS IN NORMAL BREATHING SOUNDS THE 
RESULT OF DISEASE. 

Changes in the Vesicular Murmur. — The vesi- 
cular murmur is modified by diseased states as follows : — 

1. It is jerking or interrupted. 

2. It is increased in intensity or loudness. 

3. It is diminished in intensity, more indistinct. 

4. It is altogether absent. 

5. It is commingled with bronchial breathing, by 
which it is rendered harsh and its rhythm altered. 

6. It is substituted by bronchial breathing. 



48 PHYSICAL DIAGNOSIS. 

i. Interrupted or jerking breathing is the least im- 
portant of the alterations in the vesicular murmur, being 
generally of no significance whatever. Such is its value 
in persons who are nervous or slightly alarmed during 
examination. The interruption affects most frequently 
the inspiratory act, but it may occur in either or both, 
and the act may be broken into two or three parts. 
More serious is its cause when it occurs in connection 
with severe pleurisy or pleurodynia, where the pain of 
the act of breathing causes the latter to be interrupted. 
It has here, however, no more significance than in 
nervousness. Finally it may be present in incipient 
tuberculosis or emphysema, but even here its diagnostic 
value is merely confirmatory, and that only when it 
persists. 

2. Vesicular breathing is increased in intensity by 
any cause which compels the lung or a part of it to 
assume increased function. This happens in one lung 
or a part when the other or the remainder is deprived 
of its use by compression or destruction. In this 
change both the inspiratory and expiratory factors are 
proportionally increased in loudness and in length, the 
accentuation of increase being in the inspiratory sound 
rather than with the expiratory. Its pitch is unaltered. 
From the resemblance of this exaggerated breathing, 
as it is also called, to the normal breathing in children 
it is often called puerile breathing. 

3. The vesicular murmur is diminished in intensity by 
various causes. Such feebleness affects the inspiratory 
murmur rather more than the expiratory, so that the 



ABNORMAL BREATHING SOUNDS. 49 

latter may be relatively prolonged, but it is, at the same 
time, even feebler than in health. Such diminution 
may be due to feebleness in the inspiratory act from 
debility, or to obstruction in the bronchus leading to 
the ausculted area ; or to a loss of elasticity in the air 
vesicles, as in emphysema of the lungs or the very early 
stage of tubercular deposit. More commonly in actual 
practice, it is due to the interposition of a liquid or a 
solid medium between the lungs and the ear, such as a 
pleuritic effusion or the plastic exudation of a pleurisy. 
Or it is due to the filling up of the air vesicles by an 
exudate as in pneumonia, or tubercular infiltration in 
phthisis. More frequently it is obliterated by these 
causes. 

4. The vesicular murmur is altogether removed by 
the higher degrees of the last named conditions, viz., 
pleuritic effusion, pneumonic and tubercular infiltra- 
tions. 

5. The vesicular murmur is altered by the addition 
of a bronchial element, the first effect of which is to 
lengthen the expiratory factor of the breathing sound, 
to alter, in a word, its rhythm. Coincidently with, or 
immediately succeeding upon this, is a roughening of 
both inspiration and expiration, at first slight and then 
positive. As long as this degree is maintained there is 
still a vesicular factor in the breathing, whence it was 
named by Flint broncho-vesicular breathing. Ex- 
pressive terms are also harsh respiration, rude respiration 
or rough respiration. Such modifications of normal 
breathing are brought about by an infiltration of a cer- 



50 PHYSICAL DIAGNOSIS. 

tain number of air vesicles with solid material, while 
others still maintain their function. The effect of this 
is also to improve the conducting power of the portion 
of the lung involved, so that it becomes a better con- 
ductor of the bronchial sounds elsewhere produced, 
which are thus brought to the ear. It means, therefore, 
that a certain small degree of consolidation has taken 
place. 

How shall we distinguish between puerile breathing 
and broncho-vesicular breathing, a most important 
requirement, since they indicate opposite conditions? 
Yet there is a certain similarity between them which 
inexperienced observers may mistake for identity, and 
which even an experienced man may sometimes have 
occasion to dwell on before deciding. Both are louder 
and rougher as to inspiration, but vastly different is the 
manner in which expiration is influenced. In puerile 
breathing it may be slightly longer and more distinct 
than in health, but it maintains its ratio to the length 
of the inspiratory murmur. Not so is it with the rude 
inspiration. Here the expiratory sound is roughened 
and prolonged out of all proportion to the inspiratory. 
And in catching slight degrees of difference the atten- 
tion must be concentrated on the expiratory murmur. 
If it is greatly prolonged in proportion to the inspiratory, 
so as to nearly or quite equal it, and at the same time 
harsher than in health, not simply louder, then we 
have broncho-vesicular breathing and the conditions 
which produce it. And if to this is added a slight rise 



ABNORMAL BREATHING SOUNDS. 51 

of pitch on percussion, a slight dullness, the condition 
is confirmed. Sometimes, however, these conditions 
do not go entirely pari passu. Then we must wait 
and watch. We must not forget, too, the physiological 
differences on the two sides, that there is the slightest 
higher pitch on the right in both percussion note and 
breathing sound, and that the expiratory murmur is 
slightly more distinct on the right, It must be remem- 
bered, too, that in simple feebleness of the respiratory 
vesicular murmur the expiratory element is less affected 
in its duration, but that here both inspiratory and ex- 
piratory sounds are less loud rather than more loud. 

6. Finally, the vesicular murmur may be altogether 
substituted by bronchial breathing. This means that a 
considerable area of lung has become obliterated as to 
its vesicular structure, and in this change has also become 
an excellent conductor of the distant normal bronchial 
breathing, which is heard with a blowing tubal quality 
as though produced directly under the ear. Again, it 
is to be remembered, that there is no more bronchial 
breathing produced under these circumstances than there 
was before the consolidation took place. It is simply 
that the vesicular murmur has altogether vanished, for 
the reason named, and therefore cannot longer mask the 
bronchial breathing, while the latter also is better con- 
ducted to the ear. Acute croupous pneumonia furnishes 
the most characteristic bronchial breathing. Between 
this and broncho-vesicular breathing there is every de- 
gree depending upon the degree of destruction of vesicu- 
lar tissue and the extent of consolidation. When the 



52 PHYSICAL DIAGNOSIS. 

consolidation is very intense the bronchial breathing is 
rendered more intense, more metallic even than the 
tracheal breathing sound, which may be regarded as the 
type of bronchial breathing. 

Changes in Bronchial Breathing. — The more 
usual modifications of bronchial breathing are caver- 
nous breathing and amphoric breathing. 

i. Cavernous Breathing. — The beginner will not 
be discouraged at any difficulty he may have in dis- 
tinguishing between bronchial breathing and cavernous 
breathing when he learns that at the present day the 
German clinicians do not attempt to distinguish between 
them. English and American observers have, however, 
usually separated them ; both Flint and DaCosta, for 
example, say that the sign is more likely to be con- 
founded with the normal vesicular murmur than with 
bronchial breathing, differing, says Flint,* from the 
former only in the absence in inspiratory sound of the 
vesicular quality. 

In the first place the cavernous breathing is repre- 
sented as more hollow in character, if this can be con- 
ceived, less tubal and therefore of lower pitch than 
bronchial breathing. The expiration is also commonly 
lower pitched than the inspiration, reversing, in this 
respect, the bronchial breathing, although this is not 
constant enough to be made a rule of difference. 

The conditions of its production are a cavity with 

* " Manual of Auscultation and Percussion," 5th Ed., Phila., 1890, 
p. 107. 



ABNORMAL BREATHING SOUNDS. 53 

yielding and resilient walls, by the collapse of which the 
air can be forced out, since the sound depends upon 
the entrance and exit of air. It is also often associated 
with gurgling, or may alternate with it. It may dis- 
appear to reappear after copious expectoration. Cavities 
at the apex of the lung in tubercular consumption are 
the most common causes, but whatever produces an 
excavation of the kind may cause it. A dilated bron- 
chus, an abscess and even gangrene of the lung may be 
such a cause. 

2. Amphoric Breathing. — Amphoric breathing is 
more easily recognized from its ringing metallic char- 
acter, like that of the amphoric percussion note, re- 
sembling also the sound produced by blowing upon the 
mouth of a bottle. It is produced by the same condi- 
tions, a cavity with firm walls. It is likewise a blowing 
sound, of high or low pitch, inspiratory or expiratory, 
or both. Clinically its presence most frequently means 
pneumothorax, but a phthisical cavity may furnish the 
same conditions. Every case of pneumothorax does 
not, however, produce it, since there must be a perfora- 
tion of the pleura above the level of the fluid and free 
communication with a bronchial tube. 

There are other modifications of bronchial breathing 
more or less accidental and therefore of less importance. 
Thus it sometimes happens that either the inspiratory or 
the expiratory portion is absent, when it may be still 
recognized by the pitch and quality of the portion re- 
maining cavernous. Again we may have a vesicular 
inspiration with a cavernous expiration, or there may 



54 PHYSICAL DIAGNOSIS. 

be an admixture of cavernous and bronchial breathing, 
brought about by a combination of conditions which 
need not be mentioned here. Another variety of modi- 
fication is the Seitz-metamorphosing respiration, 
in which the inspiratory sound is heard for about one- 
third of its time as harsh tubal and the remainder of 
ordinary blowing, cavernous, or amphoric quality. It 
is caused by air entering a cavity through a narrow 
opening. 

AUSCULTATION OF THE NORMAL VOICE. 

Normal Vocal Resonance. — When the ear is ap- 
plied below the clavicle of a person speaking, a confused 
monotonous humming sound is produced, of slight 
intensity, and low pitch. In the aged it is apt to be 
tremulous or somewhat bleating. This is normal vocal 
resonance. It varies, however, in intensity and pitch 
in different persons, being almost inaudible in some. 
It depends also somewhat upon the manner in which 
the person speaks and the words he utters. It is in- 
creased not so much by loud speaking as speaking " from 
the chest." It is better noted also if the patient counts 
" one, two, three," or speaks the word " ninety-nine." 
It is also feebler in women than in men. It is accom- 
panied by a fremitus, which is the same as that described 
under palpation. It is a tactile fremitus in which the 
ear is the touching part instead of the palm of the 
hand. 

Vocal resonance varies in different parts of the chest, 
being more marked where the walls are thin. Hence 



AUSCULTATION OF THE NORMAL VOICE. 55 

below the clavicles it is relatively loud, and more so below 
the right, just as is tactile fremitus, an important fact 
to be remembered in diagnosis, as well that everywhere 
on the right side it maybe more marked. Towards the 
sternal portion of the clavicular region it is louder, the 
tracheal voice influencing it. Below the clavicles it 
diminishes with the greater thickness of the chest walls 
of the mammary region, is again more marked in the 
axillae, less intense over the scapulae and louder below 
them. Between the scapulae it is also intense. 

The whispering voice also requires some allusion. 
It being borne in mind that whispering in most persons is 
an act of expiration, if the ear is applied to a thin-walled 
portion of the chest, as below the clavicle, and the patient 
asked to count in a whisper, there is heard a feeble low- 
pitched blowing sound, unaccompanied by fremitus, 
with a pitch and quality the same as those of the expiratory 
vesicular sound in breathing. All that has been said of 
vocal resonance, as to its audibleness and the degree 
thereof in different persons and on the different parts of 
the chest, is true of the " normal bronchial whisper," as 
it is called by Flint, because " the conduction of the 
sound produced by the whispered voice must be chiefly 
by the air contained in the bronchial tubes." 

Normal Bronchophony. — When the stethoscope 
is placed over the thyroid cartilage of the larynx of a 
person speaking, a much louder resounding sound is 
heard directly under the ear, accompanied also by 
a thrill or fremitus conveyed to the ear. But it is 



56 PHYSICAL DIAGNOSIS. 

still confused and no articulate words are heard. It 
corresponds to bronchial respiration as normal vocal 
resonance accords with vesicular breathing. 

If the person thus ausculted over the larynx or trachea 
whispers instead of speaks audibly, a high-pitch tubal 
sound accompanied by fremitus is heard. It is, in fact, 
the expiratory breathing sound, as heard in these air 
tubes, interrupted by the act of speech. 

Abnormal modifications of the ausculted voice. 
The correspondence of vocal resonance and normal 
bronchophony with normal vesicular breathing and 
normal bronchial breathing has been referred to. The 
same relation exists in pathological conditions. Thus 
any increase in the intensity of the normal vocal re- 
sonance implies a corresponding condensation of lung 
tissue, culminating in typical bronchophony when the 
consolidation is complete, just as the normal vesicular 
breathing passing through broncho-vesicular terminates 
in bronchial breathing. Pari passu with increased vocal 
resonance and broncho-vesicular breathing goes increased 
bronchial whisper, the usual rule of health, of slightly 
greater intensity on the left, a higher pitch on the right 
being remembered. 

Pectoriloquy. — In addition there are certain special 
modifications of the normal vocal resonance correspond- 
ing more or less to certain morbid states. Thus there 
is the cavernous voice or pectoriloquy, in which articulate 
speech is heard as though coming directly from the 
chest into the ear. While this is sometimes the sign of 



NEW OR ADVENTITIOUS SOUNDS. 57 

a cavity it is not always so, the voice being similarly 
transmitted by solidified lung. Whispering pectoriloquy 
is a much more reliable sign of a cavity. 

Amphoric voice is ringing and metallic, like the 
other amphoric sounds, and like them indicates the 
same conditions — a large cavity with firm walls. 

^Egophony is another very distinctive modification 
of the normal voice when ausculted. It is admirably 
likened to the bleating of a goat, and is produced during 
speech when there is a thin layer of liquid between the 
chest wall and the lung, in pleuritic effusions, or when 
there is liquid in the chest cavity from other causes 6 

Diminished Vocal Resonance. — Finally, speech 
sounds may be diminished in intensity by the same 
causes which diminish the tactile fremitus : pleuritic 
effusions, pleuritic thickening, compression of the lung 
by fluid or air, and by over-distention of the lung. 

NEW OR ADVENTITIOUS SOUNDS. 

These sounds are not a modification of preexisting 
sounds, but something altogether new or additional. 
They include rales or rhonchi, the friction sound, 
and metallic tinkling. 

Rales are new sounds produced in the trachea, bron- 
chial tubes or in cavities, concurrent with the movement 
of air inwards or outwards in the act of breathing. 
They are the direct result of some partial obstruction to 
the onward movement of the air, for the most part 
within the tube, but the narrowing may also be the 
result of extra-tubal pressure. They are divided into 

E 



58 PHYSICAL DIAGNOSIS. 

moist or dry rales according as the obstructing substance 
is liquid or the reverse. Both are influenced by cough- 
ing and may often be completely removed, for the time 
being, by this act. When not thus influenced by cough- 
ing they are probably due to pressure from without. 

Dry rales are due to the vibration produced in 
thickened adherent mucus or the swollen mucous 
membrane of the bronchi, by air moving over them. 
Sounds produced in the tubes of large lumen, like the 
trachea, are musical, low-pitched, and are called sono- 
rous rales. Those produced in the small tubes are 
high-pitched and hissing, and therefore called sibilant 
rales. 

Moist rales are caused by the passage of air through 
liquid, which may be blood, mucus or serum. They 
are therefore of the nature of bubbling sounds and are 
spoken of as large and small bubbling sounds, accord- 
ing as the bubbles are large or small, and as large bub- 
bles can only form in tubes of large size or cavities, 
they indicate these conditions, while the small rales 
indicate smaller tubes. The bubbling sounds are further 
subdivided, according to size, into gurgling, mucous, 
submucous, subcrepitant and crepitant rales, and crack- 
ling. 

Gurgling is a term applied to the largest bubbling 
sounds, and is produced in cavities containing fluid. It 
is also known as the cavernous rale, and has sometimes 
a metallic character when it becomes associated with the 
other metallic physical signs already mentioned as 
characteristic of a cavity with firm walls. 



NEW OR ADVENTITIOUS SOUNDS. 59 

The mucous rale is a bubbling sound smaller than 
the cavernous, but still of large size, produced in the 
trachea and larger bronchi. The death-rattle is a tra- 
cheal mucous rale. The sub-mucous rale is a smaller 
bubbling sound produced in tubes of smaller size, and 
the sub-crepitant in still smaller. The crepitant 
rale is formed in tubes of smaller size and in the air 
vesicles. It may be a true bubbling sound, or it may 
be due to the separation of agglutinated air vesicles by 
entering air. From its extreme importance in the 
diagnosis of pneumonia, although it occurs also in 
oedema of the lungs, it requires some further illustra- 
tion. It is aptly compared to the crackling produced 
by throwing salt on the fire, or rolling the hair between 
the fingers alongside of the ear ; also to the noise made 
by separating near the ear the moistened thumb and 
index finger. The first appears to me the best imita- 
tion. It is heard only in inspiration and is thus dis- 
tinguished from the sub-crepitant rale, which is heard 
in expiration as well. 

Crackling literally means the same as crepitation, 
and, in fact, the mechanism of the two signs is nearly 
the same. Both are inspiratory sounds, and both may 
be- small bubbles. The main difference is really in the 
number of crackles which go to make up the rale, the 
crepitant consisting of several of these, while the crack- 
ling consists of but one, two, or three. " Crackling " 
is heard at the apices of the lungs, and the crepitant 
rale for the most part at the base. The interpretation 
of crackling is almost invariably tubercular consumption, 



60 PHYSICAL DIAGNOSIS. 

and it means that the tubercle is beginning to break 
down. Yet we may have pneumonia of the apex. 
What is known as " moist crackling " is a little larger 
rale than crackling, a pure bubbling sound produced in 
the smallest bronchial tubes, and is really a sub-crepita- 
tion. 

The friction sound is a noise produced by the rub- 
bing of two slightly roughened serous surfaces upon 
each other. The pulmonary and costal pleurae and the 
cardiac and pericardiac serous membranes move over 
each other smoothly and noiselessly in health, but let 
them be roughened in any way by an inflammatory 
exudate, an eruption of tubercles or other morbid growth, 
and at once the friction sound is produced. In its 
simplest and most frequent form, representing the first 
stage of pleurisy, it also resembles somewhat the crepitant 
rale, and it is sometimes not easy to distinguish from it. 
In addition, however, to being more superficial in situa- 
tion, the friction sound is not influenced by coughing, 
while the crepitant rale is. The friction sound is heard 
more loudly if the stethoscope is pressed closely to the 
chest-wall and is localized, while the crepitant rale is 
heard over a large area of lung. It is also often a to- 
and-fro sound, being heard with expiration as well as 
with inspiration, while the crepitant rale is confined to 
the latter. The friction sound disappears with pleuritic 
or pericardial effusion, to return for a time with the 
subsidence of the effusion. 

In addition to its typical crepitant-like character, as 
heard in pleurisy, the friction sound assumes also at 



NEW OR ADVENTITIOUS SOUNDS. 6 1 

times greater roughness, which is more conspicuous in 
pericardial friction. Where organization has taken 
place in an exudate there is sometimes a leather-like 
creaking produced under the same circumstances as the 
friction sound, and it is regarded as a friction sound. 
It is sometimes so loud as to be heard by the patient 
himself, and may also be recognized by palpation. 
Pleural friction may be found anywhere in the chest but 
is more frequent in the sides. 

Metallic tinkling is the last of the adventitious 
sounds to be considered. It is another one of the am- 
phoric sounds, requiring a space with firm tense walls as 
its condition. A pneumothorax will furnish such con- 
dition, as also do certain pulmonary cavities. Under 
these circumstances a drop of liquid falling into such a 
space will produce metallic tinkling. This sometimes 
happens in a pneumothorax when a drop of secretion 
will sometimes fall from a bronchial tube into a cavity. 

Allied to the metallic tinkling is the Hippocratic 
succussion, produced in pyo-pneumothorax and very 
rarely in a cavity, when the patient is shaken. 



62 PHYSICAL DIAGNOSIS. 



PHYSICAL SIGNS OF ABNORMAL STATES, OR 
DISEASES OF THE LUNGS. 

ACUTE BRONCHITIS. 

Acute bronchitis of the larger tubes is essen- 
tially a symmetrical disease, the bronchi of both lungs 
being generally more or less equally invaded. There 
may be absolutely no physical signs, inspection, palpa- 
tion, percussion, and auscultation being alike negative. 
In other cases inspection may discover increased fre- 
quency of respiratory movement, and possibly increased 
frequency in the apex beat if there be fever. Palpation 
may appreciate a rhonchal fremitus if there be sufficient 
narrowing of the breathing tubes. It may be found 
anywhere or on either side and may be very transient. 
Percussion continues invariably clear so long as the 
bronchitis is uncomplicated. 

Auscultation furnishes the most distinctive and con- 
stant physical sign, the presence of dry rales, the sonor- 
ous and sibilant, which may invade either or both lungs, 
and may also be transient. To these may be added 
harshness of breath sounds. In the resolution of bron- 
chitis, bubbling rales may substitute the sonorous and 
-sibilant, in consequence of the presence of secretion. 

Capillary bronchitis involves the finer and finest 
tubules, into which it generally extends from the larger. 
The frequent breathing is more evident and constant ; 
so the frequent heart beat with fever. Rhonchus may 
be felt, and there may be slight impairment of reson- 



EMPHYSEMA OF THE LUNGS. 6$ 



ance in the affected area. Auscultation gives constant 
results in the shape, first, of dry rales of the finest kind, 
followed very soon by small bubbling rales, submucous 
and subcrepitant, but dry rales are often absent. These 
signs are most frequent in the bases of the lungs pos- 
teriorly, but may extend all over. 



CHRONIC BRONCHITIS. 

Physical signs more constantly attend chronic bron- 
chitis, yet they afford no unchanging picture. The 
frequently associated complication of emphysema of the 
lungs may be the cause of a diminished excursion of 
respiratory motion, to palpation a diminution of the 
normal vocal fremitus, and to percussion a hyper-reso- 
nance, unless in the vicinity of a superficial dilated 
bronchus filled with secretion, where there may be im- 
pairment of resonance. If such a dilated bronchus be 
emptied of its contents by expectoration, even the 
percussion signs of a cavity may be present, but in the 
middle or lower part of a lung instead of the apex. 

Auscultation may even here be negative, but much 
more frequently exhibits an alternation or combination of 
harsh breathing and sonorous rales with moist rales of all 
sizes. 

EMPHYSEMA OF THE LUNGS. 

This condition, an over-distention and destruction of 
air vesicles with a like destruction of their covering of 
capillaries, is invariably the result of bronchitis and a 



64 PHYSICAL DIAGNOSIS. 

complication of it. It also affects both lungs at the 
same time, but involves different lungs and different 
parts of the same lung unequally. 

The physical signs are more or less distinctive. In- 
spection discovers a rounded chest anteriorly and pos- 
teriorly, with bilateral enlargement, and wide intercostal 
spaces, the highest degree of which is known as the 
" barrel-shaped chest." But the emphysema may be so 
circumscribed as to produce local bulgings, by prefer- 
ence in the upper lobe of the right and lower lobe of 
the left lung. The excursion of expansion of the chest 
walls is diminished, while the scaleni and sterno-cleido- 
mastoid muscles stand out distinctly. The apex of the 
heart is displaced downwards and to the right, but it 
is often difficult to find, because covered up by the 
enlarged lung. Vocal fremitus is diminished, while 
palpation further discovers the natural resiliency sub- 
stituted by increased resistance in the chest walls. 

Percussion discovers resonance exaggerated in various 
degrees, sometimes almost tympanitic, the vesiculo- tym- 
pany of Flint. The cardiac dullness is extended to the 
right and downwards, partly from the displacement by 
the distended lungs, and partly from hypertrophy of the 
right ventricle. At the same time the cardiac area is 
more thoroughly covered by the lungs, and pretty strong 
percussion is often necessary to bring it out. The 
hepatic area of dullness is also lowered by reason of the 
encroachment of the lungs. 

The distinctive auscultatory sign of the emphysema- 
tous area is the feeble inspiratory murmur, due to the 



SPASMODIC ASTHMA. 65 

fact that the air vesicles are already distended with air 
and there is little further distention possible with the 
inspiratory act. The prolonged expiratory murmur is 
the result of the lost elasticity of the air vesicles, whence 
they recoil but slowly on their contents. Vocal reso- 
nance is diminished because of the diminished motion 
in the air columns. Feeble crackling is said to be 
sometimes heard. If bronchitis is present its sounds are 
associated and often obscure all else. The pulmonary 
second sound at the second left interspace is accen- 
tuated on account of the hypertrophy of the right 
ventricle, but the heart sounds are usually obscured by 
the extra covering of the lung. With dilatation of the 
right ventricle, which sooner or later succeeds, the 
accentuation disappears. 

Interlobular emphysema, in which the connective 
tissue between the lobules is infiltrated with air as the 
result of rupture of air vesicles from violent acts of 
coughing, or of wounds of the lung, the physical signs 
except to inspection are the same as those of vesicular 
emphysema except that the crackling sound referred to 
is more common. The configuration of the chest in 
such cases is not usually altered. 



SPASMODIC ASTHMA. 

The physical signs of this peculiar neurosis reveal 
themselves to all the methods of physical diagnosis em- 
ployed. Thus inspection discovers the most labored 
efforts in breathing, while the chest moves but slightly, 



66 PHYSICAL DIAGNOSIS. 

because the lungs cannot be inflated. The spaces 
above and below the clavicle and above the sternum, 
the intercostal spaces, and the pit of the stomach are 
drawn in, for the same cause, — that is the thoracic 
cavity not being filled from within, the external atmos- 
pheric pressure forces the yielding portions inward. 

Rhonchal fremitus is recognized by palpation, while 
vocal fremitus, obscured by the rhonchus, is otherwise 
diminished by a frequently associated emphysema. Per- 
cussion is negative in uncomplicated asthma, but asso- 
ciated emphysema may produce abnormal resonance. 

Auscultation furnishes the most striking and easiest 
recognized of the physical signs. All over the chest are 
heard sonorous and sibilant rales, inspiratory and ex- 
piratory, but more commonly the latter. In fact, for 
the most part, they do not require the ear to be placed 
close to the chest for recognition. The vesicular mur- 
mur, on the other hand, is inaudible. 

It is to be remembered that chronic bronchitis, emphy- 
sema and asthma may also complicate each other, and 
render correspondingly complex the physical signs. 



TUBERCULAR PHTHISIS OR CONSUMPTION. 

Accepting the modern doctrine, that all phthisis is 
tubercular, there are three ways in which it invades the 
lungs. 

i. As catarrhal or broncho-pneumonic phthisis. 

2. As fibroid phthisis. 

3. As miliary tuberculosis of the lungs. 



TUBERCULAR PHTHISIS OR CONSUMPTION. 6 J 

Catarrhal Phthisis. — This, the most common form 
of consumption, presents two varieties, differing mainly 
in the rapidity of their course, — whence acute and 
chronic phthisis. The former is also known as phthisis 
florida or galloping consumption. Perhaps there should 
be added, as a distinctive feature of the latter, the 
diffuseness as well as the rapidity of the process. 

Catarrhal phthisis resolves itself, with more or less 
definiteness, into three separate stages, of which the 
physical signs, commonly sought at the apices of the 
lungs, are also more or less distinctive. 

i. The incipient stage or beginning deposit. 

2. Stage of complete consolidation. 

3. Stage of softening and cavity-formation. 

1. Inspection, in the incipient stage is as often negative 
as not. A slight impairment of motion in the infra- 
clavicular space may be present, and more rarely a slight 
flattening of the same region. Page* mentions a prom- 
inence of the clavicle of the affected side as occurring. 
The body may continue well nourished or slightly ema- 
ciated, or the heart-beat in the normal position may 
be somewhat accelerated, while the respirations may also 
be slightly more frequent than is normal. Palpation 
discovers increased vocal fremitus in the same situation, 
although this may not always be recognizable in the first 
stage, while the physiological difference in favor of the 
right side is to be remembered. Percussion in this stage 
gives slightly higher pitch and impairment of resonance, 

*" Physical Diagnosis," third edition, New York, 1891, p. 113. 



68 PHYSICAL DIAGNOSIS. 

which may be noted above, on, or below the clavicle. 
Dullness may sometimes be brought out by directing the 
patient to hold his mouth open during percussion, or to 
hold his breath at expiration. 

On auscultation above or below the clavicle, we have 
the first evidence of abnormality in a .prolongation of 
the expiratory murmur and harshness in the inspiratory 
sound — the broncho -vesicular breathing described. 
Theoretically this should be preceded by a diminished 
intensity in the inspiratory sound, owing to the inter- 
ference of the newly-deposited tubercles with the move- 
ment of the air into them, but practically this is 
scarcely encountered, and if encountered is of such 
indistinctive significance as to be of little value. In- 
creased vocal resonance is a constant accompaniment 
of these modifications in the normal breathing sounds, 
but both may be masked by a pleuritic thickening, and 
the physiological difference so often referred to must be 
remembered. Da Costa also calls attention to the fact 
that in a certain number of cases, at this stage, there is 
a blowing sound in the subclavian or pulmonary arter- 
ies, and that a murmur is sometimes present in the sub- 
clavian or pulmonary artery before any other physical 
sign is present. There may be concurrent with these 
signs, those of a bronchitis more or less acute. 

2. In the second stage the changes discovered by in- 
spection are more easily recognized. There is evident 
loss of flesh. The hectic flush is intermittingly present. 
Palpation may also discover an increased warmth of 
skin. The increased vocal fremitus should be plainly 



TUBERCULAR PHTHISIS OR CONSUMPTION. 69 

recognized unless obscured by a thickened pleural mem- 
brane. Dullness is positive, as is also increased vocal 
resonance. 

The bronchial factor in the breathing now becomes 
conspicuous, showing itself by the harshness and short- 
ening of the inspiratory element, with the decidedly 
rough and blowing expiration ; also a gradual diminu- 
tion of the vesicular element, until the latter disappears 
entirely, and we have the typical bronchial breathing 
of extended areas of tubercular infiltration. This sign 
will now be found in the supra-spinous fossa as well. 
The high degree of vocal resonance, known as broncho- 
phony, is now superadded as a valuable confirmation of 
complete consolidation. The auscultation signs of a 
concurrent bronchitis may also be present in this and 
the next stage. 

3. In the third stage the information furnished by in- 
spection is still more decided. Emaciation is extreme, 
and breathing and pulse rapid, the face often flushed. 
In this stage the superficial veins over the involved area 
may be prominent, partly from emaciation and partly 
from obstructed circulation. The vocal fremitus is still 
more marked, and even remains distinct over cavities, 
because of the consolidation around them, unless there 
be some obstruction to the entrance of air in the bron- 
chus leading to the involved area. Rhonchal fremitus 
may be added if adventitious sounds are present. The 
skin is hot and dry, and sometimes harsh unless suc- 
ceeding one of the sweats which characterize this stage, 
when it may be moist and clammy. 



7<D PHYSICAL DIAGNOSIS. 

Dullness on percussion is always to be found in the 
third stage, but to it is constantly added some of the 
varieties of tympanitic note referred to, pure tympany, 
the ' cracked-pot' sound or amphoric resonance, due to 
cavities. These require sufficient size and superficial 
situation on the part of the cavity, and the other 
conditions described on pages 37, 38, 39 and 40. On 
the other hand, resonance may even be normal over a 
cavity some distance from the surface, especially if the 
percussion be lightly made. 

In the third stage there may be continued the bron- 
chial breathing of the second, but to it may be super- 
added the distinctive signs of a cavity, which may also 
supplant those of the bronchial breathing. These signs 
are cavernous breathing, cavernous voice, amphoric 
breathing and amphoric voice, pectoriloquy, either whis- 
pering or with the ordinary voice, the full import and 
condition of all of which have been described. To 
these are often added the large bubbling sounds known 
as gurgling, caused by the air bubbling through the 
fluid in a cavity. Metallic tinkling may be added to 
these phenomena, caused by the bursting of bubbles in a 
cavity with the amphoric conditions. 

Fibroid Phthisis or Cirrhosis of the Lung. — 
Fibroid phthisis does not admit of the same sharp divi- 
sions into stages which characterize catarrhal phthisis. 
Frequently traceable in its initial symptoms to the inhala- 
tion of irritating substances, and much more chronic in 
its course even than the chronic form of catarrhal 
phthisis, the general clinical history is of great value in 



TUBERCULAR PHTHISIS OR CONSUMPTION. 7 1 

distinguishing it from the latter. It is constantly asso- 
ciated in its beginning with pleurisy and it may be a 
sequel of it. The phenomena of retraction as noted 
by inspection are more marked and extensive, and are 
not confined to the apex of the lung. The heart is 
frequently dislocated and the apex correspondingly 
displaced, sometimes to an extreme degree. The inter- 
costal spaces are often narrowed, the diaphragm may be 
drawn up. The modifications of vocal fremitus as 
revealed to palpation are not nearly as constant, being 
masked by the retraction and pleuritic complications, 
and may be absent. There is little or no elevation of 
temperature. Percussion is more constant in its phe- 
nomena, there being marked dullness and a wooden- 
like resistance. There is sometimes hypertrophy of the 
right ventricle due to the extra effort of the right heart 
to propel the blood through the obstructing lungs. 
Auscultation most frequently discovers bronchial breath- 
ing and exaggerated voice, but both of these may be 
lessened in intensity by thickened pleurae. 

A dilated bronchus is a frequent result furnishing 
the signs of a cavity, which may be in the middle or 
even at the base of the lung, and furnishes a copious 
expectoration characterized by a peculiar fetor. 

To the signs of the fibroid state in a part of a lung 
are frequently added those of emphysema in the re- 
mainder or in the other lung. 

The rarity with which the bacillus tuberculosis is 
found in the sputum in this condition is not regarded as 



72 PHYSICAL DIAGNOSIS. 

sufficient to exclude it from the category of tubercular 
diseases. 

Acute miliary tuberculosis is not accompanied 
by any distinctive physical signs, and the diagnosis is 
made from the clinical and hereditary history rather 
than from such signs. 

Not every case of tuberculosis of the lungs begins in 
the apex, nor even when it does thus begin are the 
physical signs always first discovered anteriorly. Ex- 
amination of every case should therefore include the 
posterior portion of the lung, and especially the supra- 
spinous fossae. Tuberculosis not very rarely succeeds 
upon a pneumonia as well as pleurisy, and especially a 
catarrhal pneumonia, when the signs first make their 
appearance in the area which has been made vulnerable 
by the previous state. 



PNEUMONIA. 

Acute croupous or lobar pneumonia, more 
common in the right lower lobe, presents three easy 
separate sets of physical signs corresponding to as many 
stages in the morbid process itself. 

The first, or stage of congestion, in which the air 
vesicles are still open, is of short duration, terminating 
within the first twenty-four hours, and may therefore 
be overlooked. Inspection discovers the face flushed, 
increased frequency of respirations, with restricted move- 



PNEUMONIA. 73 

ment upon the involved side and exaggerated motion 
on the sound side. The patient lies by preference on 
the affected side because of the greater comfort it gives 
him. This posture not only diminishes the pain by 
hindering the motion of the affected side, but also 
lessens the dyspnoea by permitting unrestrained expan- 
sion of the side which is doing the work. 

Palpation at first may even find diminished vocal 
fremitus on account of the relaxation of the air vesicles, 
but vocal fremitus becomes decidedly increased as the 
air vesicles fill up. The skin is hot and the pulse is fre- 
quent. Percussion gives but slight if any impairment 
of resonance. In fact, tympany or the vesiculo-tympany 
of Flint is frequently present in this stage as the result 
of the relaxation of the partially filled air vesicles, 
giving resonance by immediate relaxation. Seep. 35. 

In the very earliest stage the vesicular murmur 
may be feeble, but very soon comes the distinctive 
physical sign of pneumonia, the crepitant rale at the end 
of expiration, or if there be coincident pleurisy — pleuro- 
pneumonia — the closely simulating friction sound may 
be added. But all of these physical signs, even if care- 
fully sought for, may be wanting if the pneumonia is 
deep-seated, as not infrequently happens, appearing as 
the surface is reached, or they may not be recognized 
at all if it remains central. Over the normal part of the 
lung, however, there is exaggerated vesicular breathing. 

The second stage, or stage of red hepatization or 
solidification, lasting four or five days, furnishes unmis- 
takable signs. All the signs pneumonia reveals to 

F 



74 PHYSICAL DIAGNOSIS. 

inspection in the first stage are intensified in the 
second, and the breathing is markedly abdominal. To 
palpation, vocal fremitus is now intense, the skin is hot 
and dry, and the pulse continues frequent. 

Percussion gives absolute flatness over the solidified 
area, with high pitch and short duration, except in those 
very rare instances alluded to on p. 39, where the 
extreme consolidation throws the column of air in the 
trachea and bronchi into vibration, producing tympany. 
This explanation is perhaps the only one when it occurs 
in the upper lobe. In a lower lobe, tympany may result 
in the same way, from the proximity of a dilated stomach. 
Over the adjacent normal areas, also, resonance is ex- 
aggerated in consequence of the supplemental action of 
these parts. There may even be here tympany or vesi- 
culo-tympany due to the relaxation of the adjacent air- 
vesicles, an instance of resonance by mediate relaxation. 
Even cracked-pot sound may be produced by percussion 
over the solidified lung as the result of the sudden 
expulsion of air from a large bronchus leading to the 
solidified area. 

Auscultation discovers high-pitched bronchial breath- 
ing over the solidified lung. Indeed, these are the 
circumstances which give the typical bronchial or tubal 
breathing. The air vesicles are obliterated, and the 
resulting excellent conducting medium brings the 
tracheo-bronchial blowing to the ear. The ausculted 
voice gives us typical bronchophony and occasionally 
even pectoriloquy as well as whispering bronchophony 
and pectoriloquy. The heart sounds are also heard with 



PNEUMONIA. 75 

great distinctness over the consolidated lung, owing to 
the improved conduction, while the sounds of a concur- 
rent bronchitis are similarly intensified. A lingering 
crepitant rale may also be heard. 

The third stage or stage of grey hepatization or reso- 
lution occupies six to ten days. It repeats largely, to 
inspection, palpation, and auscultation, the phenomena 
of the first. Resonance continues impaired for some 
time. The normal manner of breathing gradually 
returns, the temperature of the skin is noticeably less, 
the crepitant rale returns, technically known as the 
" crepitans redux," and is finally replaced by the normal 
vesicular breathing sound, by which time the dullness 
has disappeared. 

Croupous pneumonia may rarely terminate in abscess 
or gangrene, when the signs of the second stage con- 
tinue, the temperature does not fall, in a word the crisis 
does not occur. The signs of a cavity which might 
naturally be expected are rarely present, and it is rather 
by the general symptoms, the failure to recover, the 
continued high temperature, the expectoration of pus, 
and, in the case of gangrene, the intensely disagreeable 
odor, that informs us of the issue. These issues probably 
represent on a large scale what takes place in every in- 
stance in minute areas in the third stage of all pneu- 
monias which terminate favorably. The occasional 
termination in tubercular phthisis exhibits a similar 
arrest of the resolving process in the second stage, and 



76 PHYSICAL DIAGNOSIS. 

the phenomena of the catarrhal or fibroid phthisis 
supervene. 

The obscuring effect of a thickened pleura upon ail 
of these signs is to be remembered, and too much stress 
cannot be laid upon the fact that we may have a central 
deep-seated pneumonia which may give no physical 
signs, also that in old persons the physical signs of a 
pneumonia are very apt to be delayed from one to 
three days. 

Catarrhal or Lobular Pneumonia or Broncho- 
Pneumonia, — The physical signs of this form of pneu- 
monia are not nearly so distinctive as those of croupous. 
A circumscribed affection involving a few lobules, the 
physical signs are necessarily more obscure. Occurring 
most frequently in the course of a bronchitis in children 
and in old persons, as well as de novo in the former, the 
physician should be on the watch for it under these 
circumstances. It also occurs in adults, though more 
rarely, especially in those suffering from tuberculosis, as 
the result of insufflation of broken down tubercular 
matter, which produces by inoculation and irritation a 
tubercular broncho-pneumonia. When superadded to a 
bronchitis under any of these conditions, there ensues 
increase of fever, embarrassed breathing and associated 
increased inspiratory effort. Palpation should discover 
increased vocal fremitus if the area involved be suffi- 
ciently large, percussion should reveal dullness, with 
possible increased vocal resonance and tympanicity of 
adjacent supplementally acting areas. Auscultation will 



PNEUMONIA. 77 

also discover in the inflamed area the crepitant rale, the 
bronchial breathing and bronchophony, in addition to 
the physical signs of the concurrent bronchitis. 

Embolic Pneumonia and Hemorrhagic In- 
farct. — Pulmonary Apoplexy. — The effect of the 
lodgment of an embolus from any source in a branch 
of the pulmonary artery is to produce an extravasation 
of blood in the conical area formerly supplied by the 
vessel. Such an extravasation is called a hemorrhagic 
infarct. It is in fact a circumscribed apoplexy, but the 
term apoplexy of the lung is better retained for such 
extravasations of blood, circumscribed or diffuse, as are 
due to rupture of branches of the pulmonary artery from 
other causes than embolism. Such is over-distention of 
blood-vessels in valvular disease of the heart, disease of 
the blood-vessel wall, or traumatism. 

Small infarcts of the lungs may give rise to no symp- 
toms whatever. When large enough they cause sudden 
embarrassed breathing, rusty expectoration and circum- 
scribed dullness, all of which increase with the size of 
the infarcted areas. Palpation reveals increased vocal 
fremitus, and auscultation crepitant and sub-crepitant 
rales, bronchial breathing and bronchophony. These 
are the signs of a croupous pneumonia which is indeed 
present, the consequence of the infarct which acts as 
an irritant. The circumscribed area covered by these 
signs would exclude an ordinary croupous lobar pneu- 
monia, while the absence of fever, the suddenness of 
onset and the presence of cardiac disease aid in the 
diagnosis. 



78 PHYSICAL DIAGNOSIS. 

Similar symptoms may be caused by massive hemor- 
rhage of the lungs or pulmonary apoplexy, caused by 
the rupture of a large branch of the pulmonary artery 
whose wall is weakened by tuberculous infiltration or 
the engorgement due to valvular heart disease. Such 
a vessel may suffer a further strain in consequence of 
some transitory congestion, and rupture occurs. A 
great mass of blood is poured out, which, besides enter- 
ing the bronchial tubes and producing haemoptysis and 
mucous rales, also infiltrates the lungs, coagulates and 
produces consolidation. If the patient lives, the blood 
in the bronchi may be insufflated into the vessels and 
there act as an irritant, producing intense inflammation 
followed by gangrene or abscess. 

Pulmonary oedema furnishes many of the signs of 
the first stage of croupous pneumonia, and is accompa- 
nied by a frothy pinkish expectoration ; but the absence 
of fever, and the presence of dropsy elsewhere, or its 
causes, account for the condition. 

Collapse of the Lung. — In the course of a capillary 
bronchitis there sometimes occurs a collapse of a portion 
of the lung, owing to a valvular plugging of a bronchus, 
as the result of which air may pass out during expiration 
but cannot enter with inspiration, or it may occur as the 
result of a want of strength to fill the air-cells. The 
area of collapse often corresponds in size with that of 
lobular pneumonia. 

When such collapse occurs there is sudden difficult 
breathing noticed on inspection, but palpation gives 
no information. Percussion discovers dullness, but it 



PLEURISY. 79 

is much less marked than in lobular pneumonia, while 
auscultation gives no bronchial breathing, or if it does, 
it is very feeble ; no bronchophony, but rather dimin- 
ished intensity of breathing sounds and diminished 
voice. Collapse of the lung is apt to be symmetrical. 

Cancer of the lung furnishes signs of consolidation 
very similar to those of the second stage of tubercular 
consumption. Flattening, dullness, blowing breathing, 
or bronchial breathing, all except elevation of tem- 
perature may be present, and it is the history of the 
case and special symptoms that determine the diagnosis 
rather than the physical signs. History of heredity, 
cancer elsewhere, cachexia, more constant and severe 
pain, are symptoms of importance in the diagnosis. 
A peculiar currant-jelly-like sputum is much mentioned 
as characteristic. 



PLEURISY. 

Acute pleurisy is also resolvable into three stages, 
each of which is characterized by physical signs more or 
less distinctive. They include a dry stage, a stage of 
effusion and a stage of resolution or absorption. 

The first or dry stage is characterized anatomically by 
the presence of the so-called lymph or exudate on the 
pleural surfaces. During this is revealed to inspection 
a restrained expansion of the affected side, often thrown 
into jerks or catches because of the pain suffered in a 
continuous inspiration. The expansion on the opposite 
side, on the other hand, is full and unhampered. The 



80 PHYSICAL DIAGNOSIS. 

patient is apt to lie on the affected side. Very rarely 
does palpation recognize a fremitus corresponding to the 
friction of the two pleural surfaces. Percussion in this 
stage is negative, but auscultation recognizes the friction 
sound already described. It may be at a single spot 
in the infra-mammary or infra-axillary space, and hence 
be overlooked. At other times it may be noted over a 
considerable area. 

The inflammatory process may stop here and resolu- 
tion take place, or it may continue into the second or 
stage of effusion. The signs of this stage vary with 
the amount of liquid in the sac. With a small amount, 
the lungs are slightly floated up, and there may be no 
signs unless there be a vesiculo-tympany above the line 
of the fluid, a Skodaic resonance by mediate relaxation 
of the air vesicles. 

The effusion, however, rarely remains so trifling, but 
commonly rises to the mid-chest. In the upright posi- 
tion of the patient, inspection discovers in a spare person 
shallowness and perhaps obliteration of the lower inter- 
costal spaces. The motion of the chest wall is lessened 
both in the vertical and transverse directions. 

To palpation vocal fremitus is diminished over the 
area of effusion, but may be increased in the lung 
above it. To percussion there is absolute flatness over 
the area of effusion, but the line of demarcation is 
not everywhere at the same level, being higher behind 
than in front. The late Dr. Calvin Ellis first called 
attention to an S-like curve in the line of demarcation 
which is said to be diagnostic. Very important in the 



PLEURISY. 8 1 

diagnosis is the fact that the fluid changes its level, and 
with it the line of dullness, when the position of the 
patient is changed. There is also an abnormal sense of 
resistance to the finger in percussing over the area of 
effusion. Above the effusion, especially anteriorly, there 
is again Skodaic resonance by mediate relaxation, and 
even sometimes a cracked-pot sound. Tympany may 
also be present, due to the proximity of a distended 
stomach. 

To auscultation, the breathing sounds are inaudible 
or very feeble, as compared to the corresponding por- 
tion of the opposite side, but vocal resonance, though 
diminished, is still well heard where the collection of 
fluid is moderate. Above the line of dullness there is 
occasionally a friction sound, and close to the root of 
the lung bronchial breathing may be heard. This is, 
however, more apt to be the case when the effusion is 
larger and the lung is further compressed. Egophony 
is also sometimes heard. 

When the effusion is larger, filling up two-thirds or 
three-fourths of the pleural sac, the effects described are 
increased, while new ones are added. Respiratory 
movement is still more hampered, the intercostal spaces 
are widened and even bulging, while fluctuation may 
sometimes be recognized in them. The heart is dis- 
placed by the accumulated fluid, and if it be in the left 
sac, the apex is often found far over to the right of the 
median line, and if on the right, the apex is pushed 
further to the left. Its sounds are not, however, altered 
further than to be heard more intensely in the situation 



82 PHYSICAL DIAGNOSIS. 

where they are not usually so heard, because sound is 
transmitted more readily through a single uniform 
medium than through two or more of different densities. 
On the opposite side, the breathing movements are sup- 
plementally increased. There is complete absence of 
vocal fremitus. 

Percussion is absolutely flat all over the effusion, 
and Skodaic resonance is not now obtainable because 
the lung is too thoroughly compressed up into the 
apex of the sac. Resistance to pressure is marked. 
Bronchial breathing is, however, heard at the upper pos- 
terior of the lung, because the large tubes are still per- 
vious to air, and the compressed lung intensifies the 
sound. Sometimes bronchial breathing is heard in 
more peripheral parts of the chest, probably conducted 
hither along a band of adhesion or along a rib. Else- 
where there is absence of breath-sounds. Vocal reso- 
nance and whispering voice are alike absent, or the 
former is very feeble. In certain situations, too, high 
up, where there is but a thin film between the chest-wall 
and the lung, there may be egophony, but this is more 
apt to be present as the fluid is being absorbed. 

In the third stage, if resolution takes place with a 
gradual retrocession of the fluid and the reexpansion of 
the lung, we have a return to normal physical signs. 
There may be, too, a friction redux. A considerable 
time is, however, required for absorption, and it is 
often many days before the normal breathing sounds 
are heard with their usual intensity or the natural fre- 
mitus is felt. Often resolution is not complete, and 



PLEURISY. 8$ 

there then remain the symptoms and sequelae of a 
chronic pleurisy. 

Chronic Pleurisy. — Its symptoms and sequelae are 
not uniform. The simplest and most harmless expres- 
sion is a thickened pleural membrane. In this there is 
no adhesion between the opposite pleural surfaces, and 
the motion of the lung is not interfered with. There 
is, however, a general interference with the conduction of 
sound, and all the normal physical signs, including vocal 
fremitus, vocal resonance, normal percussion sounds 
and normal breathing sounds are diminished in inten- 
sity. For the same reason many abnormal physical 
signs, as already more than once instanced, are also 
less plainly heard. 

The harmful symptoms of chronic pleurisy are more 
frequently manifested in the results of delayed absorp- 
tion of effusion, and in a change of its character from 
serous to purulent. The resulting accumulation of fluid 
in the pleural cavity is not always a continuation of 
acute disease. A chronic pleurisy may originate de novo, 
and often without the consciousness of the patient, 
although a careful analysis of the case will not fail to 
find symptoms of ill-health which are explained by the 
state of affairs ultimately found. Such pleurisies are 
known as latent. With the discovery of the effusion, 
which may depend more or less on the acumen of the 
physician, the latency disappears. 

Such fluid furnishes the physical signs which have 
already been detailed on p. 80. Its further effects vary 
very much according as it is serum or pus. In either 



84 PHYSICAL DIAGNOSIS. 

event its speedy removal is desirable, because the longer 
it remains compressing the lung, the longer will the latter 
be in returning to its natural state. Hence, it is better 
done by aspiration than by the slower method of medi- 
cation. If the fluid be serous, and if it has not been too 
long retained, the lung gradually resumes its normal 
state, and a thickened pleura is all that remains, with 
the physical signs referred to as associated with it. Not 
infrequently, however, the two pleural surfaces, costal 
and pulmonary, remain permanently agglutinated, and 
then, although the lung slowly resumes its natural func- 
tion, there still remains some flattening over the lower 
part of the thorax. 

If the liquid be pus, we have an empyema, and the 
consequences are much more serious. The occurrence 
of a chill and continued high temperature will suggest 
a purulent collection. Baccelli's test may be tried.* 

Medical treatment almost never removes it, and aspi- 
ration is as invariably followed by reaccumulation. 
Hence, permanent measures, as the introduction of a 
drainage tube or exsection of a rib, must be used. 
Even here, if the drainage tube be inserted early, the 
lung may resume its natural office, and there may be 
no more permanent damage than the agglutination re- 

*Baccelli, of Rome, in 1875, suggested a method of distinguish- 
ing purulent accumulations from serous. He found that the whis- 
pered voice was often audible over these serous accumulations, while 
it was inaudible over pus collections. Douglas Powell, Transac- 
tions of International Medical Congress, 1881, failed to confirm this 
observation. 



PLEURISY. 85 

ferred to, and subsequently a retracted thorax. More 
frequently, however, we have to do with a lung partly 
bound by adhesions into its new and unnatural posi- 
tion, while the pleural surface may be looked upon as 
an extensive ulcer. The restrained lung is unable to 
expand to refill its natural space, while the huge ulcer 
referred to must heal slowly with a resulting cicatrix. 
This cicatrix has the property of all cicatricial tissue. 
It must contract, and with this contraction drags with 
irresistible force whatever is attached to it, including 
the ribs and eventhe spinal column, which is sometimes 
drawn out of line. Thus there results distortion, in 
various degrees, of the shape of the thorax, associated 
with a shortness of breath which is permanent, but 
which may, nevertheless, grow less as time rolls on. 

A result of empyema which remains to be alluded to 
is a circumscription of pus into two or more separate 
or communicating spaces, which may even be multiple. 
It is not always easy to recognize such a state of affairs. 
Most frequently it is ascertained by the attempt at 
removal by tapping, the withdrawal of a certain amount 
of fluid giving partial relief and leaving areas with physi- 
cal signs unchanged. Da Costa gives us from Jaccoud * 
some points to assist towards such recognition. Given, 
in the area of dullness, a zone along which vocal vibra- 
tions are preserved, as from the spinal column towards 
the sternum, and a separation between two portions of 

*Da Costa, op. citat., p. 366, from Bulletin de l'Academie de 
Medecine, 1879. 



86 PHYSICAL DIAGNOSIS. 

fluid probably exists along such line. Again, if voice and 
fremitus continue, though feebly, except in a zone of a 
few finger-breadth behind, and at the lower border of 
the chest, while no tympanitic sound can be elicited 
under the clavicle, it may be concluded that the effusion 
is multilocular. When diaphragmatic adhesions exist, 
the normal movements at the epigastrium and bypo- 
chondrium are reversed, and inspiration is accompanied 
by depression in the lower intercostal spaces instead of 
a filling out. 

One other feature must be pointed out as associated 
with such collections, and that is pulsation sometimes 
communicated to them by the heart. Hence the 
term pulsating empyema. Such a one recently 
occurred to the writer. It was below the left clavicle, 
and so striking that he hesitated to puncture it lest it 
be a pulsating auricle or an aneurism. The knowledge 
that there was pus elsewhere in the pleural sac, the 
elevation of temperature and the absence of sound or 
murmur or thrill seemed to justify operation, and a large 
quantity of fetid pus was drawn through a communi- 
cation made with a pus cavity lower down. The tumor 
and pulsation and fever disappeared and the patient, who 
was a girl, recovered. 



PNEUMOTHORAX- 

This comparatively frequent complication of tuber- 
cular consumption, commonly results from the rupture 
into the pleural sac of a cavity in the lung, an accident 



PNEUMOTHORAX. 8 J 

usually brought about by a fit of coughing. This re- 
sults in a rapid filling of the pleural cavity with air, 
which is soon followed by an effusion of liquid, generally 
purulent. The result is a distended air sac occupied to 
a certain height with liquid, compressing somewhat the 
lung and displacing the heart, while the physical condi- 
tions are those of a resounding cavity. 

The effect on the physical signs is as follows : To in- 
spection a bulging chest, a filling out of the intercostal 
spaces. The thoracic wall on the affected side diminishes 
its excursion of respiratory movement, or it appears at a 
standstill. Palpation discovers no vocal fremitus. Per- 
cussion furnishes over most of the half of the thorax in- 
volved, the most striking of the percussion notes, the 
ringing, amphoric resonance, which contrasts strongly 
with the absolute dullness due to the fluid below. To 
auscultation the breathing sounds are distant and feeble, 
the expiratory sound continuing short, but the voice is 
ringing, amphoric, and an unmistakable tinkling sound 
attends the dropping of fluid from the perforation into 
the fluid below. To a sudden shaking of the body there 
results a splashing sound similarly intensified by the re- 
echoing to which it is subjected. 



88 PHYSICAL DIAGNOSIS. 



PHYSICAL EXAMINATION OF THE HEART. 

Anatomical Relations of the Heart. — The actual 
boundaries of the heart in the chest cavity demand 
some notice. The base of the heart is held fast by the 
great vessels coming from it, but the remainder of the 
organ has a certain freedom of motion chiefly rotatory, 
but slightly also of elongation, limited only by the peri- 
cardial sac attached to the diaphragm and pleurae. The 
heart lies upon the central tendon of the diaphragm. 
The auricles are nearly transversely placed, on a level 
with the third costal cartilages, both extending slightly 
beyond the corresponding borders of the sternum. The 
ventricles are obliquely placed, the right being in front 
and directly under the sternum, extending beyond both 
edges but more to the left. It is on a level below with 
the sixth cartilage. A much smaller portion of the left 
ventricle is turned to the front when the heart is in situ, 
and it is altogether within the line of the nipple, the 
apex corresponding to a point between the fifth and sixth 
cartilages and an inch and a-half below and within the 
nipple. The base of the heart corresponds behind with 
the fifth and sixth dorsal vertebrae, between which and 
it lie the aorta and oesophagus. The heart surrounded 
with its pericardial sac is covered very largely by the 
lungs, the right extending to the middle of the sternum, 
the left also to the middle as low as a line continuous 
with the lower edge of the fourth cartilage, along 
which it passes across the fourth interspace and the fifth 



ANATOMICAL RELATIONS OF HEART. 89 

rib, the lung covering the whole of the left ventricle 
except the apex. 

The Prsecordium. — By the prsecordial region 
or prsecordium is meant that portion of the thorax 
covering the heart, and it may be said to be bounded 
above by a line drawn through the junction of the manu- 
brium with the blade of the sternum, below by a line 
drawn along the upper edge of the sixth cartilage, and 
laterally by a vertical line drawn through the seat of 
the apex-beat, and another three-fourths of an inch to 
the right of the sternum. In this region inspection and 
palpation discovers the apex-beat between the fifth and 
sixth ribs and an inch and a-half below and within the 
nipple. In children it may be found an interspace 
higher, and in the aged and persons with long and 
narrow thoraxes it may be an interspace lower. Occa- 
sionally, in the second interspace to the left of the . 
sternum in thin persons, a feeble impulse can be seen 
produced by the dilatation of the left auricle. The 
situation of the apex is slightly altered by changes 
of position or by distention of the stomach from any 
cause. The act of breathing, however, influences it 
most. With a deep breath the heart descends and is 
pushed inward by the inflated lung, and the impulse 
approaches the epigastrium. On a deep expiration it 
rises slightly, and while the breath is held remains 
higher. The apex-beat is rendered more distinct by 
exercise or emotion. This is still more the case in patho- 
logical states where there is enlargement. Emphysema 
of the lungs and effusion into the pericardial sac render 

G 



90 PHYSICAL DIAGNOSIS. 

it more or less indistinct. Its position is also variously 
changed by morbid conditions, and a thrill or fremitus 
is sometimes communicated to the hand in valvular 
diseases. 

Fremitus is also sometimes noticeable as the result of 
pericardial friction. The whole praecordial region is 
sometimes abnormally prominent in hypertrophy and 
pericardial effusions, especially in the young, while 
retraction due to adhesion is also seen. In the neigh- 
borhood of the praecordium, at the root of the neck, pul- 
sations, arterial and venous, are noted, also epigastric 
pulsations, which will be explained under the head of 
the conditions that produce them. 

PERCUSSION AND AUSCULTATION OF NORMAL HEART. 

The percussion boundaries of the heart have 
been already mapped out on page 29, but it may not be 
amiss to review them at this point somewhat more in 
detail. 

The Percussion Borders of the Heart. — To 
map out the percussion borders of the heart, we begin 
percussing on a horizontal line at the left edge of the 
sternum, at about the second interspace, proceeding 
downward by moderately strong percussion, only, until 
positive dullness is reached. This is usually found to 
be on the fourth costal cartilage, which is the upper 
border of the uncovered area of the heart, and where a 
line should be drawn. We then begin to percuss on a 
vertical line at the right edge of the sternum below the 
fourth rib, and proceed across the sternum until dull- 



Fig. 12. 




Showing Absolute and Relative Percussion Dullness of Liver and Heart. 



92 PHYSICAL DIAGNOSIS. 

ness is reached, which is in most cases towards the 
left edge of the sternum, and this is the right border of 
the absolute dullness of the heart, and here a vertical 
line is drawn. The situation of the apex is then found 
by palpation or by the stethoscope. Percussion is again 
commenced on an oblique line in the direction of a line 
from the junction of the fourth cartilage with the sternum 
towards the apex, but sufficiently beyond to be certain 
of clearness. Then parallel with such a line proceed 
downwards until positive dullness is reached. The 
lower border of the heart cannot be satisfactorily sepa- 
rated by percussion from the liver, but such a boundary 
can be obtained with sufficient accuracy by drawing a 
line from the apex perpendicular to the sternum. Thus 
the area of absolute dullness in adults will corre- 
spond to a rough triangle of which the base is 2^ to 3 
inches, the perpendicular 2^ inches and the hypothe- 
nuse 2)% to 4 inches on a somewhat curved line. 

The area of relative dullness, elicited by stronger 
percussion, extends a short distance in every direction 
except downward. The exact measure of this must 
depend somewhat on the delicacy of the ear of the 
examiner, and the mode in which he percusses, but it 
may be put down approximately as a finger's breadth, 
and on the left within the nipple line in adults. 

In children, the area of the cardiac dullness is de- 
cidedly reduced on acount of the intense resonance of 
the child's thorax. In old age, on the other hand, 
the area of absolute cardiac dullness is increased on 
account of the shrinkage of the lungs. The upper 



PERCUSSION AND AUSCULTATION OF HEART. 93 

border of absolute dullness is at the fifth rib, and the 
apex may be in the sixth interspace. 

The effect of a deep inspiration is materially to di- 
minish the area of dullness, while that of expiration 
enlarges it. Pathologically the normal area is increased 
downwards to the left in hypertrophy of the left ven- 
tricle, downwards towards the epigastrium and to the 
right in hypertrophy of the right ventricle. 

The auscultation of the normal heart is very 
simple. It consists in the recognition of the normal 
heart-sounds, known as first and second. Both sounds 
are audible over the whole praecordial region in health, 
but the first sound, characterized by its longer, boom- 
ing character and lower pitch, is heard most loudly at 
the seat of the apex beat, where it is the louder of the 
two. The second, shorter, sharper, higher-pitched, 
and more snapping in character, is most intense at the 
base of the heart, on the sternum opposite the second 
interspace. Both sounds are heard at both situations, 
but each has its situation of greatest loudness. Hence, 
at the apex the rhythm may be said to be represented 
by the trochaic foot — ^, while at the base it is repre- 
sented by the iambus — — . The two sounds have also 
been long compared to the word lub-tub, the first 
syllable corresponding to the first sound, and the 
second to the second part. While this word cannot 
be said to resemble the heart-sounds very closely, there 
seems to be no other that resembles it more. 

As to the mechanism of the sounds, while that of 
the first is probably somewhat complex, including the 



94 PHYSICAL DIAGNOSIS. 

shutting down of the auricular ventricular valves, the 
apex beat, the rush of the blood through the aorta and 
pulmonary artery, and the noise of the muscular con- 
traction, it is sufficient for clinical purposes to consider 
it produced, as it undoubtedly is for the most part, by 
the shutting down of the auriculo-ventricular valves, the 
mitral or bicuspid on the left side, and the tricuspid on 
the right. Both sets of valves shut down simultane- 
ously, both contribute to the production of the sound, 
while the greater muscular power of the left side gives 
to it a distinct predominance. The second sound is of 
simpler mechanism, and is caused solely by the shutting 
down of the semilunar valves of the aorta and pulmo- 
nary artery with the recoil of the blood upon them. On 
account of the more powerful recoil in the aorta, the 
aortic is the predominating sound. We may, however, 
isolate the part of each set of valves by carrying the 
stethoscope to certain situations, and in diagnosis con- 
stant advantage is taken of this. Thus, in order to pick 
out the mitral part of the first sound, the stethoscope is 
placed at the seat of the apex beat, while the tricuspid 
factor is best heard at the left sternal border, between 
the fifth and sixth cartilages. So with the second sound, 
the aortic factor is best heard at the second interspace 
to the right edge of the sternum ; and the cartilage just 
above this is known as the aortic cartilage, because 
this great vessel approaches next to the chest-wall in 
this situation. The pulmonary part of the sound, on 
the other hand, is heard at the left edge of the sternum 
at the second interspace, while the cartilage above this, 



PERCUSSION AND AUSCULTATION OF HEART. 95 

behind which ascends the pulmonary artery, is called 
the pulmonary cartilage. These points, and a circle 

Fig. 13. 




Diagram showing location of cardiac valves and points of maximum intensity 
connected with them. The triangle a b c is the area of superficial dullness. — 
After Page. 



about an inch in diameter around them, are known as 
the mitral, tricuspid, aortic and pulmonary areas. 



g6 PHYSICAL DIAGNOSIS. 

It is to be remembered, however, that these are not 
the precise seats of the valves themselves. These are 
all situated in wonderfully close proximity to each other 
— in fact a portion of each is contained within a space 
of less than half an inch square. The mitral valve is 
placed behind all the others, at a point corresponding 
to the left border of the sternum at the third interspace, 
vertically ^upwards across the attachment of the third 
. costal cartilage. The tricuspid valve corresponds to 
a line drawn obliquely across the sternum from the third 
left interspace to the fifth costal cartilage of the oppo- 
site side. The aortic valve lies nearly horizontally 
behind a line joining the middle of the sternum and the 
end of the third left costal cartilage. The pulmonary 
valve, a little higher and to the left of the aorta, runs 
quite horizontally, corresponding to a line drawn along 
the upper border of the third left costal cartilage. The 
want of identity of the auditory valve area, or place 
where the sounds are best isolated, with the actual sites 
of the valves, is due to the fact that the sounds are best 
heard at points on the chest-walls nearest the cavity or 
channel in which vibrating blood is flowing. 

The normal heart-sounds are heard less loudly over 
the normal areas during deep inspiration, when they 
are more completely covered by the fully expanded 
lungs, and the first sound is heard more loudly at a new 
point towards the median line to which the apex is 
pushed by the inflated lungs. On the other hand forced 
expiration increases the area over which the sounds are 
heard. 



ABNORMAL MODIFICATION OF HEART-SOUNDS. 97 

The time of the normal heart-sounds requires some 
further study because on a thorough understanding of 
this depends largely skill in diagnosis. The first sound 
begins with the systole of the ventricles and is coinci- 
dent with the apex-beat, the second occurs in the dias- 
tole, immediately after the first with a short pause 
between. The second sound is succeeded by a longer 
pause occupied with the diastole of the ventricles during 
the latter part of which occurs the systole of the auricles, 
terminating the diastole of the ventricles. Thus if 
a revolution of the heart's sounds and pauses be repre- 
sented by a dash and interspaces we will have the fol- 
lowing : — 

1st sound. 2d sound. 1st sound. 2d sound. 1st sound. 2d sound. 

I Short ■ Long I ■Short ■ | Long I ■ Short ■ 



8B^ ause -Bii Pause. I JPause | 

It is to be remembered that each one of these sounds 
is double, two systolic occurring at the ventricular ori- 
fices, and two diastolic at the aortic and pulmonary ori- 
fices. It may be further conceded that the first sound 
as heard at the base of the heart and the second sound 
as heard at the apex are simply conducted from the 
seat of their production, and that they are in no part 
produced at the situation where they are less loud. 

ABNORMAL MODIFICATION OF HEART-SOUNDS. 

It is not impossible, even in health, to have these 
paired sounds separated, and thus is produced what is 
known as reduplications of the heart-sounds, a phe- 
nomenon more common in diseases of the heart. Thus 



98 PHYSICAL DIAGNOSIS. 

as the effect of running there may result such an engorge- 
ment of the lesser circulation that as the result of high 
tension in the pulmonary artery, the pulmonary valve 
closes a little sooner than the aortic, and reduplication of 
the second sound occurs. In like manner the closure of 
the tricuspid valve may be retarded, the synchronism 
destroyed, and reduplication of the first sound thus pro- 
duced. The first sound is reduplicated at the end of 
expiration and beginning of inspiration, the second at 
the end of inspiration and the beginning of expiration. 
The same and similar conditions operate to produce 
reduplication of the heart-sounds in disease. 

The intensity of the heart-sounds is greater in 
persons with thin chest-walls, and under the influence 
of excitement. Abnormally the feverish state and gen- 
eral hypertrophy have the same effect, but the latter is 
more apt to influence the sound of the particular cavity 
which is hypertrophied. The heart-sounds are often 
heard with unusual distinctness at points distant from 
their normal areas because of consolidation of adjacent 
lung. Intensification or accentuation, as it is called, of 
the aortic or pulmonary element of the second sound 
is caused by whatever produces increased tension in 
the arterial or pulmonary circulations. Heart-sounds 
are also sometimes made ringing by their proximity 
to a cavity with firm walls or even a tensely distended 
stomach. 

Abnormally, heart-sounds are rendered less intense by 
general and cardiac weakness, fatty degeneration of the 
myocardium, pericardial, and pleural effusions, and 



ABNORMAL MODIFICATION OF HEART-SOUNDS. 99 

emphysematous lungs which cover up the heart more 
completely. 

Abnormal Heart-Sounds or Murmurs are 
modifications of the normal sounds, superadded to 
them or altogether substituting them. These are pro- 
duced within the cavity of the heart, and are accord- 
ingly known as endocardial. In addition an altogether 
new sound is engendered external to the heart, and 
therefore called exocardial or pericardial. To this the 
term murmur is also applied, although the mechanism 
of its production is so widely different it does not seem 
to me desirable to perpetuate the practice. 

The endocardial sounds or heart murmurs are 
sounds produced by an alteration in the conditions of 
normal blood currents either by structural changes in the 
heart or its valves, or in the composition of the blood. 

The former are called organic murmurs, the latter 
functional or accidental.* Both are the result of 
vibrations or oscillations in the blood stream produced 
by the causes referred to, and not of a friction between 
the blood current and the narrowed orifices or inequal- 
ities on them. Hydraulic laws teach us that when a 
fluid passes through a tube the walls of which it wets, a 
thin film of fluid becomes attached to the inner wall 
over which the remainder of the fluid moves without 
friction. So it is with the cardiac cavity and its valves 

*The term inorganic is sometimes applied to the functional mur- 
murs, but this word has another meaning so definite, that of mineral, 
that it seems almost misleading to apply it in the sense referred to 
in the text. 



IOO PHYSICAL DIAGNOSIS. 

over which the blood moves. Further, while a fluid is 
passing along a tube of uniform diameter at a moderate 
speed, no murmur results, whether the inner wall of the 
tube be smooth or rough. A murmur is only produced 
when the tube becomes -suddenly narrower and then 
widens again, and the greater the narrowing the less 
speed of current required to produce the murmur. 
Thus the vibrations arise and thus the sound is produced. 
In the case of functional murmurs which apparently 
occur without the intermediation of sudden narrowing, 
we must suppose such a change in the composition of 
the blood, either as to its density or viscidity, which 
permits it to be more readily thrown into vibration. In 
either event there is a derangement of that normal adap- 
tation of the column of blood to the orifices and cavities 
through which it has to pass, which, under ordinary 
circumstances, permits the function of the heart to be 
performed noiselessly except so far as its normal sounds 
are concerned. In the case of the organic murmurs the 
alteration is produced by the various valvular defects to 
which the heart is subject, in that of the functional 
murmurs by the various anaemias which are principally 
associated with such murmurs. 



ORGANIC MURMURS. 

An organic murmur may be produced at any one of 
the four cardiac orifices, mitral, tricuspid, aortic or 
pulmonary. They are far more common at the. mitral 
and aortic. 



ORGANIC MURMURS. 101 

Murmurs are also classified as systolic and diastolic. 
Systolic murmurs occur during the systole of the ven- 
tricles, diastolic murmurs during their diastole, and 
these alternate with the apex beat. A diastolic murmur 
which immediately precedes the systole is called a pre- 
systolic murmur. Murmurs are further classified as 
direct and indirect. Direct murmurs are those which 
arise in the blood current as it is flowing in the normal 
direction ; indirect are those which arise in a current 
flowing opposite to the natural direction. The order in 
which murmurs are considered is of little importance. 
Their great frequency seems a sufficient reason for tak- 
ing up mitral murmurs first. 

Mitral Murmurs. — The mitral systolic or mitral in- 
direct munnur. — During the systole of the ventricles the 
auriculo-ventricular orifices in a perfect heart are closed 
in order to prevent the return of the blood to the 
auricles, while the aortic and pulmonary orifices are 
wide open to carry the blood into -these great vessels, 
while the ear placed at the apex hears mainly the first 
sound. If, however, there be a defect in the mitral 
valve as the result of which it closes imperfectly, then, 
during the systole a stream of blood will flow back- 
wards into the left auricle accompanied by a murmur. 
This is the mitral systolic murmur and it means incom- 
petency or insufficiency of the valve and regurgi- 
tation of blood. The mitral systolic murmurs are 
almost invariably best heard in the mitral area at the 
apex, and are conducted into the left axilla and under 
the angle of the left scapula. Rarely, however, they 



102 PHYSICAL DIAGNOSIS. 

are heard just to the left of the pulmonary area, prob- 
ably because the vibrations are conducted into the 
appendage of the auricle and are best heard where 
this approaches nearest the surface, namely, an inch 
and a-half to the left of the pulmonary area. This 
occurs more frequently, too, with functional murmurs. 

Mitral diastolic and presystolic murmurs, or mitral 
direct murmurs. — During the diastole of the ventricles 
the aortic orifice is closed and the mitral orifice open, 
and the blood flows noiselessly into the left ventricle, 
the filling of which is finally completed by the systole 
of the auricle. If, however, the mitral orifice be nar- 
rowed from any cause, the blood column is thrown into 
vibration and a murmur results — a diastolic murmur. 
When, as sometimes happens, the narrowing or stenosis 
is not sufficient to cause a murmur throughout the entire 
diastole, but only when the additional momentum is 
given to the blood by the systole of the auricle, a mur- 
mur occurs only at this time — that is, just before the 
systole commences. It is then called presystolic. These 
murmurs mean, therefore, mitral stenosis, which is, 
however, generally associated with incompetency of the 
mitral valve. The diastolic murmur is, for the most 
part, soft, but the presystolic is rough, and is character- 
ized by Flint as " bubbling, " being compared by him 
to the vibration by the lips caused by blowing the breath 
through them. A presystolic thrill, felt at the apex of 
the heart, often accompanies the murmur. These mur- 
murs are best heard in the mitral area, and are not, as a 
rule, conducted thence in any direction. 



ORGANIC MURMURS. 1 03 

Aortic Murmurs. — Aortic systolic or aortic direct 
murmur. — During the systole of the ventricles in health, 
the aortic orifice is wide open, and the blood flows 
noiselessly through it. If any interference with the com- 
plete opening of the orifice, or roughness or inequalities 
exist, the stream of blood is thrown into vibration, and 
the aortic systolic murmur results, heard at the base of 
the heart. Such a murmur, therefore, means narrowing 
or stenosis of the aortic orifice. It is generally 
loud and harsh, sometimes musical, heard most loudly 
in the aortic area — second right interspace — but gener- 
ally all over the chest. It is conducted into the great 
vessels of the neck with great intensity. 

Aortic diastolic or aortic indirect murmur. — During 
diastole the aortic orifice should be closed and imper- 
meable to blood. If, however, as the result of disease, 
perfect closure be impossible, a stream of blood will flow 
backwards into the left ventricle, accompanied by a 
murmur at the base, which is the aortic diastolic, and 
means always insufficiency or incompetency of the 
aortic valve. This murmur is generally soft, long and 
blowing, and varies more in the seat of its intensity 
than any other cardiac murmur. Generally loudest in 
the aortic area, but often louder than this over the mid- 
sternum, it is even well heard as low as the ensiform 
cartilage, or at the apex itself. It is also conducted 
into the great vessels of the neck, but likewise down- 
wards along the sternum. It is accompanied by a pow- 
erful heaving impulse, and the characteristic trip-ham- 
mer or Corrigan pulse, characterized by its rapid rise 



104 PHYSICAL DIAGNOSIS. 

and sudden fall. It also occurs alone, but is frequently 
associated with the aortic systolic murmur, indicating 
stenosis as well as incompetency. 

Right-sided Heart Murmurs. — The same con- 
ditions at the valve orifices on the right side of the heart 
produce similar murmurs, but they are very much rarer. 
Thus tricuspid regurgitation produces the tricuspid 
systolic murmur, and tricuspid stenosis produces the 
tricuspid diastolic murmur. These are heard in the tri- 
cuspid area at the lower part of the sternum, at its junc- 
tion with the fifth and sixth cartilage. Pulmonary 
stenosis scarcely occurring, except congenitally, pro- 
duces the pulmonary systolic murmur, and pulmonary 
regurgitation, the rarest of all, would produce a 
diastolic murmur. Both are heard in .the pulmonary 
area at the second interspace, at the left edge of the 
sternum. 

Impurity of Heart-Sounds. — In addition to the 
easily recognizable abnormal sounds described, there 
occur more or less marked modifications of the normal 
sounds due to slight defects of the valves, which render 
them less typical, whence the term impurity of heart- 
sound. They may be caused by slight thickenings or 
other changes which modify the normal closure of the 
valves, and are of uncertain significance. On the other 
hand, very decided alterations in the valves and orifices 
are sometimes found at the necropsy when no modifica- 
tions of the normal sounds were detectable during life. 

The Exocardial or Friction Sound. — The only 
true exocardial murmur is the pericardial friction 



ORGANIC MURMURS. 105 

sound caused by rubbing of the two surfaces of the 
pericardium upon each other, in health a noiseless act 
like that of the pleural surfaces. When roughened, 
however, by disease a to-and-fro sound of varying loud- 
ness and harshness is heard. The most frequent cause 
is pericarditis, but any cause which roughens the two 
opposite surfaces, such as tubercular and other morbid 
growths, will produce a friction sound. 

The friction sound sometimes resembles the intra- 
cardial murmur, but a little experience enables one to 
distinguish them. The friction sound is a superficial 
to-and-fro sound heard directly under the ear, commonly 
loud and rasping, never blowing, sometimes creaking. 
It is most loud over the middle of the heart, not syn- 
chronous with the normal heart-sounds and not con- 
ducted in the direction of the blood-current. It is often 
influenced by changes of position or by breathing. It 
may sometimes be felt by the hand placed over the 
heart. It is generally of short duration and disappears 
with the filling of the pericardium by effusion. 

A friction may rarely be produced by the rubbing of 
two pleural surfaces together over the heart or between the 
pleura and pericardium, but both of these cease with 
the holding the breath. 



FUNCTIONAL OR ACCIDENTAL OR H^EMIC 
MURMURS. 

These are murmurs produced independently of any 
alteration in the state of the cardiac valves or orifices, 

H 



Io6 PHYSICAL DIAGNOSIS. 

and are due to some condition of the blood as the 
result of which its particles are thrown into vibration 
more readily than in health. Hence they are also 
called haemic murmurs. Such condition is generally 
accompanied by a watery state of the blood ; for this 
reason they are also called anaemic murmurs. Whether 
it be this thinness which is responsible for the murmur 
or some accompaniment of such a state is not known. 
They occur in connection with various diseased states 
of the blood, as the infectious fevers, leucocythemia, 
chlorosis and the various anaemias. Functional mur- 
murs have some features which aid in their recognition, 
although it is sometimes not easy to distinguish them 
from organic murmurs. Thus: i. They are invariably 
systolic. 2. They are always soft in character. 3. They 
are most frequently basic in their situation, but they 
are also changeable in this respect. 4. Functional mur- 
murs are unattended by the unequal distribution of the 
blood and the alteration in the size of the heart and of 
its cavities, which always, sooner or later, accompany 
the organic murmurs. 



VASCULAR MURMURS. 

In the examination of arteries the stethoscope is 
applied, for the carotid, over the inner border of the 
sterno-cleido mastoid muscle, on a level with the hyoid 
bone, or at the insertion of the sterno-cleido mastoid 
muscle into the clavicle and sternum ; for the subcla- 
vian behind the clavicular insertion of the sterno-cleido 



VASCULAR MURMURS. I07 

mastoid muscle; for the brachial, on the inner border 
of the biceps at the bend of the elbow, with the arm 
partially extended, and for the crural in the popliteal 
space. Care should be taken to apply the stethoscope 
very lightly, as the pressure itself will engender a sound 
which is called the acoustic pressure murmur. This 
may be made self-audible at almost any time with suffi- 
ciently quiet surroundings by pressing upon the artery 
in front of the ear. 

Normal Arterial Murmurs. — If a stethoscope be 
thus lightly placed over the carotid or subclavian 
arteries, so as not to compress the vessels, two 
sounds are heard with each movement of the heart, the 
first corresponding to the systole of the ventricles and 
the expansion of the arteries, the second to the diastole 
of the heart and the contracting recoil of the arteries. 
The first is reasonably ascribed to the conducted aortic 
first sound, — the sound produced by the blood passing 
through the aortic orifice; also to vibration in the 
arterial wall caused by its distention. The second is 
undoubtedly the second sound of the heart conducted 
into the arteries. It is therefore feeble or absent in 
insufficiency of the aortic valves. The first of these 
sounds is occasionally heard in the abdominal aorta, 
more rarely in the brachial and femoral. The second 
sound is not thus conducted. 

Abnormal Arterial Murmurs. — Abnormal 
sounds are conducted into the arteries in valvular dis- 
ease of the heart, particularly aorticdisease, both 
obstructive and regurgitant, and rarely also in mitral 



108 PHYSICAL DIAGNOSIS. 

disease. In aortic regurgitation the first normal arterial 
sound is exaggerated so as to be heard in all accessible 
arteries, because of the rapid transition from extreme re- 
laxation to extreme tension characteristic of this dis- 
ease. In addition to this a second sound is heard in 
the femoral artery corresponding with the contraction of 
the artery. This is not to be confounded with a mur- 
mur occurring in the adjacent femoral vein caused by 
tricuspid regurgitation. 

Finally, murmurs may arise in the arteries themselves 
from any causes which produce a change in the diameter 
of the vessel, such as aneurismal dilatation, congenital 
narrowing, or narrowing due to thrombi or to compres- 
sion caused by adhesions, contraction of cicatricial 
tissue, morbid growths or inflammatory infiltration, or 
the pregnant uterus. Thus a murmur may occur in a 
branch of the pulmonary artery from pressure by a tuber- 
cular deposit or pneumonic infiltration, or enlarged 
bronchial gland, and a murmur may even be produced 
in the subclavian artery by a tubercular deposit at the 
left apex. A murmur in a branch of the pulmonary 
artery from such cause is intensified during expiration, 
while a murmur in the left subclavian from the same 
cause is said to be intensified by holding the breath at 
inspiration. Thyroid tumors in the neck also produce 
arterial murmurs by pressure. The placental murmur 
is a mixed venous and arterial murmur. 

Venous murmurs are distinguished from arterial 
murmurs by their continuousness as contrasted with 
the intermittent arterial murmur. An acoustic pressure 



VASCULAR MURMURS. 109 

murmur may be produced in any vein which is large 
enough, as the jugular and femoral, by pressing slightly 
upon it with the stethoscope, without however pressing 
so hard as to obliterate the blood current. 

Murmurs independent of such pressure are sometimes 
heard in these large veins as the result of tricuspid 
regurgitation, but the principal pathological venous 
murmur is the venous hum or bruit de diable. 
It is frequently heard in chlorotic females over the 
bulb or dilatation of the internal jugular vein ; also 
sometimes in the large intra-thoracic trunks, the supe- 
rior cava and the innominata. It is best heard on the 
right side by turning the head as far as possible to the 
left and then placing the stethoscope above the right 
clavicle behind the sterno-cleido mastoid muscle. It is 
a continuous soft murmur resembling the humming of 
a top, and by its continuousness can be readily dis- 
tinguished from an intermittent arterial murmur. This 
murmur cannot be regarded as always abnormal, since 
it is often heard in healthy individuals. Thus Win- 
terich found it in 80 per cent, of the Bavarian cuirassiers 
whom he examined. Extreme loudness may be regarded 
as an indication of abnormality. 



IIO PHYSICAL DIAGNOSIS. 



PHYSICAL SIGNS OF THE DIFFERENT 
FORMS OF VALVULAR DISEASE. 

MITRAL INSUFFICIENCY. 

This is the most common of the uncombined forms 
of valvular disease. The valve leaks, the blood flows 
backward during systole from the left ventricle to the 
left auricle. The auricle first attempting to resist the 
backward flow, hypertrophies slightly, but soon dilates, 
and the blood is crowded backwards into the lungs 
which become engorged. The right ventricle in its 
efforts to push the blood through the engorged lungs, 
hypertrophies, and the pulmonary portion of the second 
becomes louder and sharply accentuated. The com- 
pensating effect of the hypertrophied right ventricle for 
a time arrests the mischief. At this stage, perhaps, 
begins the hypertrophy of the left ventricle, which in 
all cases of mitral insufficiency presents itself sooner 
or later, although at first the double outlet for the 
blood from the ventricle would seem to demand less 
strength of the left ventricle. The right ventricle, how- 
ever, in its hypertrophied state, delivers more blood to 
the left ventricle, which demands more power to drive 
it on, hypertrophy results, and thus compensation is a 
while longer maintained. Sooner or later the tricuspid 
valve becomes insufficient, the blood regurgitates into 
the right auricle and thence into the great veins of the 
neck. The valves of these ultimately yield, the jugular 
pulse appears, and the general venous system is engorged. 



MITRAL INSUFFICIENCY. Ill 

In this engorgement the liver, stomach and kidneys 
share. Then comes transudation, dropsy, albuminuria. 
Among the latter phenomena in extreme cases are an 
enlarged, tender and pulsating liver, a symptom which 
is pathognomonic of tricuspid regurgitation, but a liver 
lifted by some pulsating agency behind it must not be 
confounded with the true pulsating liver. 

Inspection discovers the apex-beat to the left of its 
normal position and perhaps a little lower down. It 
may be in the line of the nipple or even beyond it, and 
more forcible and diffuse than in health. The outward 
dislocation of the apex-beat is due to the enlargement of 
the two ventricles. An auricular impulse may be pres- 
ent to the left of the pulmonic area, and may be presis- 
tolic and active for the auricle, or systolic and passive 
for the auricle. A bulging prsecordium may be looked 
for in young persons, and in advanced stages also a 
jugular pulse. 

On palpation the apex-beat is found more forcible 
than normal, and there may be a pulsation near the 
ensiform cartilage caused by the systole of the enlarged 
right ventricle. Sometimes an intermittent systolic 
thrill is felt in the fourth interspace in the left mammil- 
lary line. 

The radial pulse in the early stages is comparatively 
unaltered. Later it becomes frequent and irregular in 
volume. Appended, Fig. 14, is a sphygmogram of the 
pulse in advanced mitral insufficiency. It is of the type 
of the pulsus parvus irregularis . 

Percussion discovers enlargement of both the relative 



112 PHYSICAL DIAGNOSIS. 

and absolute areas of dullness, upwards in the direction 
of the left auricle, downwards to the left and also to the 
right, the right border of the heart reaching at times 
the right border of the sternum. 

Auscultation recognizes a systolic murmur in the 
mitral area, and conducted with various degrees of 
loudness into the left axilla and under the angle of the 
scapula. This direction of its conduction is the dis- 
tinctive feature of this murmur. It is usually soft, 
but occasionally rough, more rarely musical. It is also 

Fig. 14. 





^A~X3^ 


_T— _ ^-_ r- -— ~v- 





Tracing of Pulse of Mitral Insufficiency. {Da Costa.) 

sometimes well heard to the left of the pulmonary carti- 
lage, and rarely over the entire praecordium. Not 
always loud enough to be easily heard, it may be 
brought out by exertion on the part of the patient. 

The second sound of the heart is sharply accentuated 
at the pulmonary interspace until the tricuspid valve 
fails, when the accentuation vanishes. The aortic 
second sound is less strong, corresponding with the 
less degree of hypertrophy of the left ventricle. 



MITRAL OBSTRUCTION. TI3 

MITRAL OBSTRUCTION. 

This lesion occurs as an uncombined or simple form 
of valvular disease in young persons, but is very much 
more commonly combined with regurgitation. The 
orifice is stenosed and the blood is restrained from pass- 
ing freely into the left ventricle. The same backward 
effect is produced upon the left auricle, the lungs, the 
right ventricle and general venous circulation, but the 
left ventricle is not hypertrophied in simple mitral ob- 
struction, because no extra muscular effort is called for. 
Theoretically, the left ventricle should even atrophy, 
but the absence of the enlargement is of great diagnostic 
value. 

Inspection, consistently with what would be expected 
from absence of hypertrophy of the left ventricle, 
discovers little or no displacement of the apex. If 
there is any it is due to the hypertrophy of the right 
ventricle. Nor is the apex-beat increased in force. A 
left auricular impulse, pre-systolic, may be noted for the 
same reason as in mitral regurgitation, as may also a 
jugular impulse. The bulging praecordium occurs under 
like conditions as in mitral regurgitation, but is not 
often seen. 

Palpation discovers the apex-beat without undue 
force, but it may be diffuse, and an impulse may be 
felt in the situation of the apex of the right ventricle. 
The most marked feature of palpation when present is 
the pre-systolic thrill usually felt in the fourth interspace, 
but it is not constant. 



114 PHYSICAL DIAGNOSIS. 

In moderate degrees of stenosis the pulse is not 
altered ; in high degrees it is very small, from want of 
left ventricular power ; also irregular, like that of mitral 
regurgitation. 

Fig. 15. 



Tracing of Pulse of Mitral Obstruction. {Striinipell.) 

Percussion discovers cardiac enlargement in the 
direction of the left auricle and right ventricle, but not 
of the left ventricle. 

Auscultation does not discover a diastolic murmur 
in every case of mitral stenosis, because of the feeble- 
ness of the auricular contraction, especially at the begin- 
ning. Often a murmur is deferred to the time of the 
auricular systole with which the diastole terminates, pro- 
ducing the described pre-systolic murmur. In the ex- 
perience of the writer, the uncombined pre-systolic 
murmur has been so rare that he has failed to recognize 
the distinctive " bubbling' ' character pointed out by 
Flint, while modern hydraulics and acoustics do not 
permit the explanation that it is caused by a vibration of 
the free edges of the valves. The murmur when present 
is further compared to vibrating the letter r with the 
tongue, and is confined for the most part to the mitral 
area, though it may be conveyed upward, and it is even 
rarely heard posteriorly. 

Accentuation of the second sound is marked and con- 



AORTIC OBSTRUCTION. 115 

fined to the pulmonary area, because there is no hyper- 
trophy of the left ventricle. The second sound may 
also be duplicated, because of the want of synchronous- 
ness in the closure of the aorta and the pulmonary valves. 
The murmur of mitral stenosis is sometimes difficult 
to distinguish from that of aortic regurgitation, but in 
the latter there is enormous hypertrophy of the left ven- 
tricle, which is wanting in mitral stenosis. The time of 
tricuspid stenosis is identical with that of aortic re- 
gurgitation, but it is heard in a different part of the 
praecordium, — in the epigastrium. Tricuspid stenosis 
may be associated with mitral stenosis, or insufficiency, 
or both. 



MITRAL INSUFFICIENCY AND STENOSIS. 

More frequently stenosis is an annexation to a pre- 
vious insufficiency when we have the double mitral mur- 
mur, sometimes with difficulty divisible into its two parts. 
Extreme irregularity of rhythm and pulse, with frequency 
and smallness of the latter, conspicuous thrill, marked 
right-sided hypertrophy, and sharply accentuated pul- 
monic sound are characteristic. 



AORTIC OBSTRUCTION. 

This is a frequent form of valvular disease, and when 
uncombined with regurgitation the least dangerous. 
The aortic orifice is narrowed and prevents the free dis- 
charge of blood from the left ventricle into the aorta. 



Il6 PHYSICAL DIAGNOSIS. 

The ventricle attempts to overcome this, and its walls 
hypertrophy in proportion to the degree of resistance, 
and often for a long time compensate for the obstruc- 
tion — until dilatation occurs, when the mischief really 
begins. 

Inspection and palpation discover a forcible apex- 
beat beyond the normal situation and at varying dis- 
tances in accordance with the degree of hypertrophy, 
while palpation adds occasionally a purring basic thrill 
with each beat of the heart when dilated hypertrophy is 
established. 

The pulse is the pulsus tardus, slow in reaching its 

Fig. 16. 



Tracing of Pulse of Aortic Obstruction. ( Vierordt.) 

maximum volume which is small. It is frequent but 
regular, contrasting in the latter respect with the 
pulse of mitral disease. Fig. 16 is a sphygmogram. 

Percussion discovers dullness downwards and later- 
ally towards the left, since, as a rule, the enlargement is 
confined to the left ventricle. 

Auscultation discloses a systolic basic murmur, loudest 
at the aortic area— second interspace at the right 
of the sternum — which is conducted distinctly into 
the carotids, and even sometimes along the course 
of the aorta, behind and to the left of the vertebral 



AORTIC REGURGITATION. 117 

column, into the popliteals and dorsal arteries of the 
feet. It is not, however, confined to this area, but may 
be heard over the entire praecordium. It is usually 
rough, but may be soft and musical. It is made louder 
by exercise. The second sound in its aortic factor is 
weak if the constriction be at all decided, because of 
the feeble recoil due to the small amount of blood in 
the aorta. The first sound is normal and somewhat 
louder and more prolonged than natural, because of the 
powerful contraction of the left ventricle. 

Roughness of the aorta due to atheroma, dilatation 
or narrowing of the vessels by pressure or otherwise, 
may also cause a systolic murmur, and so may rough- 
ness within the ventricle in the course of the outgoing 
column of blood ; but these causes have generally a less 
positive effect upon the substance of the heart. In like 
manner anaemic or haemic murmurs, which are always 
systolic and for the most part basic, may simulate aortic 
systolic murmurs, but these occur in young, delicate per- 
sons, of both sexes, and are often intermittent and with- 
out other effect on circulation. There may be rough- 
ness, too, in the pulmonary artery which can be localized 
to the left of the sternum. 



AORTIC REGURGITATION. 

The most serious and irremediable of the valvular 
diseases of the heart commonly met with ; less frequent 
than aortic stenosis, but still not uncommon even un- 
combined. It is the lesion most frequently followed by 



n8 



PHYSICAL DIAGNOSIS. 



sudden death. The aortic valves are incompetent and 
the blood flows backward into the left ventricle during 
diastole. The ventricle seeking to restore the balance 
redoubles its energy, hypertrophies. The blood is thus 
driven into the aorta with great force, swelling the 
arteries to extreme fullness, which, however, falls away 
presently, because of the backward flow into the ven- 
tricle at the same time with the forward movement into 

Fig. 17. 



Tracing of Pulse of Aortic Regurgitation. {Striimpell.) 



arteries and capillaries. This sudden falling away of 
the pulse, from extreme distention to collapse, is very 
characteristic of this form of valvular disease, and is 
called the "trip-hammer" or "water-hammer pulse," 
also Corrigan's pulse. It may even be visible to the 
casual observer in the exposed arteries, such as the 
carotid, temporal and radial, while the aortic beat, 
ordinarily beyond reach in the supra-sternal notch, may 



AORTIC REGURGITATION. 119 

sometimes be felt in this situation. The abrupt jerking 
impulse with sudden recoil is easily recognized by the 
finger, which, however, fails to find the pulse as strong 
and hard as would be expected from the appearance. 
On the other hand, it is soft and receding. A tracing 
of this pulse is found on the opposite page. It is the 
typical pulsu s celer. 

The tremendous systole of the ventricle may ulti- 
mately force the mitral valve to yield, and the compen- 
sation to be gradually lost pari passu with a growing 
dilatation. To this succeed the phenomena of mitral 
regurgitation, including hypertrophy of the right ven- 
tricle, which again comes for a time to the rescue, but 
weakens with the giving away of the tricuspid valve. 

Inspection often discovers the praecordium promi- 
nent, with the apex-beat lowered and to the left, and 
the visible pulsation far beyond the normal situation of 
the apex, all confirmed by palpation, which discovers, 
too, sometimes a systolic thrill over the carotids and 
subclavians. A capillary pulse is also sometimes visible 
in the skin and mucous membrane. The former may be 
brought out by drawing a pencil lightly across the skin 
of the cheek or forehead and on the mucous membrane 
of the everted lower lip, as suggested by F. C. Shattuck, 
by pressing a glass microscopic slide against it. 

Percussion reveals increased dullness to the left and 
downward. 

Auscultation reveals a diastolic murmur, long and 
various in quality, but usually blowing and harsher than 
the aortic obstructive murmur. Its area of maximum 



120 PHYSICAL DIAGNOSIS. 

intensity is commonly at the aortic interspace, but not 
always, being sometimes heard most loudly at mid- 
sternum, sometimes at the fourth left costal cartilage, 
and even at the ensiform cartilage. Hence it may be 
mistaken for the mitral obstructive murmur and for the 
murmur of tricuspid disease, but both of these, be it 
remembered, is unaccompanied by hypertrophy of the 
left ventricle. The murmur is naturally directed down- 
ward along the sternum in the direction of the regurgi- 
tating column, but it is also heard in the direction of 
the great vessels of the neck though less loudly than the 
aortic systolic murmur. 



AORTIC STENOSIS AND REGURGITATION. 

This double lesion is a comparatively frequent one, 
indeed commonly regarded as the next in frequency 
after mitral obstruction, and therefore more frequent 
than either aortic stenosis or aortic regurgitation alone. 
It occasions a double basic murmur, systolic and dias- 
tolic, and is also a grave condition giving rise to the 
same dangers as aortic regurgitation, and the same 
enormous hypertrophy of the left ventricle. 



TRICUSPID REGURGITATION. 

Tricuspid regurgitation as a primary condition is 
extremely rare, and when present is probably the result 
of an endocarditis during foetal life. More frequently 
it is one of the terminal events of mitral disease, 



TRICUSPID REGURGITATION. 121 

the tricuspid orifice yielding to the tension upon the 
right ventricle consequent upon the resistance to the 
movement of the blood through the engorged lungs. It 
is associated with the dilatation of the right ventricle 
which succeeds upon its hypertrophy if the patient live 
long enough. It is also one of the possible sequela of 
emphysema of the lungs and long standing fibroid 
phthisis. Its effects depending upon the venous circula- 
tion have already been detailed, p. in. 

In primary tricuspid disease with regurgitation, inspec- 
tion and palpation discover an apex beat diffused about 
the normal area toward the epigastrium, and percus- 
sion detects enlargement toward the right edge of the 
sternum. 

The systolic murmur thus engendered is invariably 
feeble and is heard almost alone in the tricuspid area 
just above and to the left of the ensiform cartilage. 
Occasionally only is the second pulmonic sound accent- 
uated. There should be no confounding of this mur- 
mur with that of aortic regurgitation conducted towards 
the same situation nor with that of mitral regurgitation 
heard at no great distance, for the reasons named. To 
these must be added a difference in quality and pitch 
between the tricuspid and the mitral murmur. The 
jugular pulse is also more or less constantly associated 
with tricuspid regurgitation, which is further confirmed 
by the pulsating liver when present. The jugular pulse 
is systolic in time and does not appear until the valves 
situated at the opening of the internal jugulars into the 
innominate veins yield. These give way first on the 
i 



122 PHYSICAL DIAGNOSIS. 

right side because the communication is more direct. It 
is sometimes not easy to distinguish a true jugular pulse 
from a false one, but pressure on the vein above the 
valves will cause the false pulse to disappear while the 
true pulse, coming from the right ventricle, will remain. 



TRICUSPID OBSTRUCTION. 

Still more rare is tricuspid stenosis, also when present 
a congenital defect associated with others. F. C. 
Shattuck has met one instance of tricuspid stenosis 
with mitral stenosis and regurgitation, along with 
adherent pericardium, hepatic cirrhosis and slightly 
granular kidney, confirmed by autopsy. In this case 
there was a pre-systolic tricuspid murmur observed for 
three years before death. This would, of course, be 
the murmur diagnostic of the condition, but frequently 
there is no murmur audible in connection with such a 
lesion found at necropsy. Theoretically, also, there 
should be enlargement of the right auricle. 



PULMONARY OBSTRUCTION. 

Pulmonary stenosis is a congenital condition occa- 
sionally seen in children, when it should furnish a 
systolic murmur in the pulmonary area, to the left of 
the sternum. The murmur may even be heard behind, 
between the shoulders. It is accompanied by hyper- 
trophy of the right ventricle. There may be a basic 
thrill, as in aortic obstruction, but the pulse is unin- 



CONGENITAL DEFECTS. I 23 

fluenced. Compensation may be set up by means of a 
patulous foramen ovale, an open ductus arteriosus or 
interventricular communication. The invariable asso- 
ciation of cyanosis due to venous obstruction, and ot 
attacks of dyspnoea, complete the picture and aid greatly 
in the diagnosis. Anaemic murmurs at the same time 
and place are unaccompanied by cyanosis. 



PULMONARY REGURGITATION. 

Simple pulmonary regurgitation is scarcely known, 
but it is easy from what has gone before to deduce the 
physical signs which are to be expected. A diastolic 
murmur heard in the pulmonic area, hypertrophy of the 
right ventricle, jugular pulse, venous congestion and 
cyanosis. 

CONGENITAL DEFECTS. 

Congenital defects in the cardiac valves and orifices 
deserve a passing notice. They may be the result of en- 
docarditis during foetal life or of arrest of development. 
Their most frequent seat is the right heart and the most 
frequent form is stenosis of the pulmonary orifice, the 
effects and signs of which have already been consid- 
ered. Another is a permanently patulous foramen 
ovale; or there may be a defect of the septum of 
the ventricles, or a communication between the aorta 
and pulmonary artery— a persistent ductus arteriosus — 
or between the aorta and the vena cava or right auricle. 



124 PHYSICAL DIAGNOSIS. 

All of these intercommunications produce murmurs 
difficult to separate, and it is, after all, by attention to 
the general condition that the defect is recognized. 
The patient, a child of arrested development, more or 
less permanently cyanosed, with continued embarrassed 
breathing, all of these are symptoms which point to the 
congenital defect. If there be added to these a persist- 
ent loud murmur at the base of the heart without other 
signs or symptoms of valvular disease, this may be due 
to congenital defect. 



RELATIVE FREQUENCY AND DANGER OF VAL- 
VULAR DEFECTS. 

The order of frequency of simple chronic valvular 
defects, as given originally by Walshe, and perhaps as 
nearly correct as can be arrived at, is as follows : — 

i. Mitral regurgitation. 

2. Aortic obstruction. 

3. Aortic regurgitation. 

4. Mitral obstruction. 

5. Tricuspid regurgitation. 

6. Pulmonary obstruction. 

7. Tricuspid obstruction, ) 

-n t -4. j.- r scarcely known. 

8. Pulmonary regurgitation, J J 

The same author estimates the following as the order 
of frequency of the combined affections : — 

1. Mitral regurgitation and aortic obstruction. 

2. Aortic obstruction and regurgitation. 



VALVULAR DEFECTS. J 25 

3. Mitral regurgitation and aortic regurgitation. 

4. Mitral regurgitation, aortic obstruction, and re- 
gurgitation. 

5. Mitral obstruction and regurgitation. 

6. Mitral obstruction and aortic obstruction. (?) 

7. Mitral obstruction and aortic regurgitation. (?) 

The relative gravity, beginning with the most serious, 
is also given by Walshe, as follows : — 

1. Tricuspid regurgitation. 

2. Mitral obstruction and regurgitation. 

3. Aortic regurgitation. 

4. Pulmonary obstruction. 

5. Aortic obstruction. 

It will be remembered, however, that I have said that 
aortic regurgitation is the most irremediable of the val- 
vular defects, at least of the more common forms, and 
the most serious from the standpoint of tendency to 
sudden death. It will be noted that no place is assigned 
by Walshe to mitral obstruction alone, and it is indeed 
difficult to assign the final position of this lesion. In 
this view most clinicians agree. 



ACUTE ENDOCARDITIS. 

The two well-acknowledged forms of endocarditis, 
simple and infectious or ulcerative, furnish no 
distinctive physical signs by which they can be recog- 
nized one from the other. It is rather by the his- 
tory and symptoms that such distinction is made, the 



126 PHYSICAL DIAGNOSIS. 

almost invariable succession of the former upon rheuma- 
tism and of the latter on some coexisting infectious 
state being valuable aids. 

Both have their most frequent site on the left side, 
the most vulnerable, and in the mitral leaflets. A sys- 
tolic mitral murmur, in the course of a rheumatism, 
means almost invariably an endocarditis. The aortic 
leaflets may also be the seat of inflammation, though 
more rarely, when a basic murmur is the consequence. 
But not every aortic murmur in the course of rheu- 
matism implies endocarditis, as the condition of the 
blood predisposes to a haemic murmur. Unless there 
has been previous valvular disease, there is no enlarge- 
ment, so that neither palpation, inspection nor percus- 
sion gives any information. 



PERICARDITIS. 

The only distinctive physical sign in the first stage of 
pericarditis is the friction sound, described on p. 104. 
In addition the impulse may be strong. 

The second stage, or that of effusion, has usually, but 
not always, signs discoverable to inspection and palpa- 
tion. The precordium may be bulging and the inter- 
spaces obliterated, and the impulse undulating, tumultu- 
ous and indistinct. Percussion furnishes the most 
striking change. The area of dullness is enlarged and 
peculiarly enlarged. It becomes rudely triangular, with 
the apex towards the inner end of the left clavicle and the 
base as low as the seventh rib, and extending in extreme 



DISEASES OF THE MYOCARDIUM. 1 27 

cases from nipple to nipple. Auscultation confirms 
palpation, the impulse is feeble, indistinct and often 
tumultuous. The heart-sounds are indistinct and best 
heard at the top of the sternum. 

The third stage consists of a gradual return to the 
normal state of affairs, which may be by the intermedia- 
tion of a friction re dux or not. Adhesions may result 
between the heart and the sac, embarrassing its move- 
ments permanently, and producing retraction of the 
chest-wall with systole. On the other hand, necropsy 
has often revealed close adhesions between the heart 
and the pericardium which were not suspected during 
life. Permanent roughening by organization in chronic 
pericarditis may produce permanent friction sound. 

Hydropericardium, as a part of a general dropsy, is 
a rare condition, and furnishes the same physical signs 
as the inflammatory effusion. 



DISEASES OF THE MYOCARDIUM. 

The heart is subject to alterations in its muscular sub- 
stance independent of valvular defect. Simple hyper- 
trophy, fatty infiltration, and fatty metamorphosis or 
true fatty degeneration, are the most important. Myo- 
sitis, abscesses, and aneurisms of the walls of the heart 
are such rare conditions that they need only to be men- 
tioned in passing, especially as there is no way to recog- 
nize them before death. 

Hypertrophy of the left ventricle, without val- 
vular disease, is always the result of obstruction to the 



128 PHYSICAL DIAGNOSIS. 

movement of the blood through the aorta beyond the 
valves, or to some demand for compensation. The most 
common remote cause is chronic Bright' s disease. Any 
variety of chronic Bright's disease may cause it, but it is 
most frequently associated with chronic interstitial neph- 
ritis. We have nothing to do here with the mechanism of 
its production except to say that it seems likely that it 
is in some way compensatory. Atheroma and aneurism 
of the aorta are attended by less degrees of hypertrophy, 
also compensatory, because of the loss of the elastic 
force in the arteries, requiring additional power on the 
part of the heart muscle. 

Inspection and palpation furnish much the same 
information as in hypertrophy of the left ventricle from 
valvular disease. Percussion shows enlargement to the 
left and downwards. To auscultation there is no 
murmur but a distinctive intensification of the aortic 
second sound is heard, quite characteristic, and itself of 
great diagnostic value. 

Pure hypertrophy of the right ventricle is the 
result of emphysema of the lungs, and sometimes to 
a less degree of fibroid disease of the lungs, compression 
of the lungs by effusion or adhesion, or of any cause 
which resists the movement of the blood through the 
lungs. We have here the signs of enlargement in the 
direction of the right heart also without murmur, but 
with sharp accentuation of the second sound at the pul- 
monary interspace to the left of the sternum. 

General hypertrophy or physiological hyper- 
trophy or symmetrical hypertrophy of both sides of the 



DISEASES OF THE MYOCARDIUM. 1 29 

heart may be brought about by severe muscular exercise, 
demanding extra nourishment. Exophthalmic goitre is 
often accompanied by the same condition, due to over- 
nourishment the result of vaso-dilator influence on the 
blood-vessels. 

Dilatation of the Heart, either of its right or left 
ventricle, may occur independent of valvular disease. 
A heart cavity is said to be dilated when it is enlarged 
out of all proportion to the thickness of its walls, even 
though the latter may be somewhat thicker than normal. 
Commonly, however, the walls are thinner or no thicker 
than in health, and when the muscular wall is thick- 
ened while the cavity is enlarged we commonly speak 
of the condition as hypertrophy with dilatation. 
The term simple dilatation is used to indicate undue 
enlargement of the cavity while the walls remain of 
normal thickness ; attenuated dilatation where the 
walls are thinned. 

Dilatation without valvular disease occurs in conec- 
tion with vesicular emphysema when, of course, it is in 
the right heart, and succeeds hypertrophy. What- 
ever causes obstruction to the outward flow of blood 
from a ventricle may cause dilatation, which is always, 
however, preceded by hypertrophy. Aneurism is such 
a cause, therefore, for the left heart. Acute infectious 
disease may also cause it, and sometimes no cause is 
discoverable. 

Inspection and palpation discover a diffuse feeble 
impulse and the pulse is weak. Percussion elicits 
signs of enlargement while auscultation finds the sounds 



130 PHYSICAL DIAGNOSIS. 

generally feeble and indistinct. I speak now of dilata- 
tion without valvular disease. When valvular disease 
is present its signs are superadded. 

Fatty infiltration or obese heart is often a part of 
the condition of general obesity, and has the same causes. 
It is something very different from the true fatty heart in 
which the muscular fasciculi are converted into granular 
fat. In the fatty infiltration the fat first covers the surface 
of the heart, then insinuates itself between the fasciculi, 
and although these are never themselves invaded, in ex- 
treme cases they undergo degeneration and atrophy from 
the pressure of the intervening fat. The heart is therefore 
not only embarrassed by the fat around and between its 
fibres but the integrity of its essential substance may 
also be impaired by interference with its nutrition, and 
occasionally death results from sudden failure, just as 
in true fatty metamorphosis. 

Such a heart is usually somewhat symmetrically en- 
larged, but the heart sounds are feeble and indistinct, 
and the same is true of the impulse. There are of 
course no murmurs unless the condition be complicated 
with valvular disease. 

Its recognition is based chiefly on the association 
of the symptoms of cardiac weakness with general 
obesity. 

True fatty metamorphosis consists in an actual 
substitution, to a greater or less extent, of the muscular 
substance of the heart by granular fat. Such a heart 
muscle is soft and. flabby and its contraction power is 
greatly impaired. 



THORACIC ANEURISM. 131 

The physical signs of such a condition are not at all 
distinctive. There is feebleness of sounds and impulse. 
The latter as well as the pulse may even be inappreci- 
able. There may be some enlargement of the heart, the 
result of dilatation of the soft and yielding muscle. 
Nor is there murmur unless there be valvular disease. 
It is rather by watching a case over a considerable 
period of time that the truth is arrived at. Treatment 
is without result and its total inefficiency is an aid in 
diagnosis. Fainting is frequent and sudden death the 
usual termination. 

Acute myositis associated with acute rheumatism 
or fever may be a cause of fatty degeneration, but there 
is no way to determine its presence. 



THORACIC ANEURISM. 

Thoracic aneurism occurs in the arch of the aorta, 
in its ascending, transverse and descending portions, 
and in the thoracic aorta below the arch. The greater 
frequency of aneurism in the male sex and during early 
middle life may be mentioned in passing. 

Inspection does not always discover changes, but if 
the sac grows outwardly, sooner or later a swelling 
makes its appearance, to the right of the sternum if in 
the ascending limb, possibly raising a rib or the end of 
the clavicle; above and behind the sternum, if in the 
transverse portion, raising the manubrium or boring its 
way through it ; and to the left of the sternum if in the 
descending limb of the arch. Such a tumor may pul- 



I32 PHYSICAL DIAGNOSIS. 

sate or not. The aneurism is, as it were, a rudimental 
heart, dilating with every jet of blood that is shot into 
it so long as the wall is yielding. Should this property 
be lost, either as the result of calcification, or the lin- 
ing of the sac with successive layers of coagulum, such 
dilatation becomes impossible, and pulsation does not 
occur. The pulsation is, however, of great importance 
in the diagnosis. When present it is synchronous with 
the systole of the ventricles. The heart itself is some- 
times displaced downward, as may be recognized by 
the lowering of the apex. 

If the aneurismal tumor press upon the great veins 
of the neck there may be venous engorgement on 
one side of the neck or both, according as the innomi- 
nate of one side only is compressed or the descending 
cava itself. 

Palpation also discovers the impulse of the aneurism 
if it is visible, and sometimes when it is not visible. 
This beating is somewhat peculiar, being expansile, and 
by this peculiarity differs from the rising of a tumor 
over a blood-vessel. A thrill is also often felt, a vibra- 
tion in the walls of the sac caused by the whirl of the 
blood in it. It is by no means, however, invariable, 
and it may come and go. 

Percussion over the swelling of an aneurism invari- 
ably gives dullness, varying greatly in extent, and 
sometimes altogether absent. On the other hand, the 
adjacent lung may be compressed by an aneurismal 
tumor, and the area of dullness thus extended. 

Auscultation is no exception, as compared with the 



THORACIC ANEURISM. 1 33 

other modes of physical investigation, in the incon- 
stancy of its results; sometimes furnishing the most 
distinctive signs, while at others it is totally negative. 
The sounds heard by the ear in listening over an 
aneurism are various. Sometimes they are like those 
of the heart, the first intense and prolonged, the second 
fainter and shorter. Sometimes but one sound is pro- 
duced, corresponding with the first sound over the 
ventricles, but more intense. But the sound which is 
commonly sought over an aneurism is the murmur or 
bruit, supposed to be caused by the rush of the blood 
through the sac. As such it is usually single and sys- 
tolic, though it may be double, or only diastolic. It is 
sometimes musical. The murmur is, however, often 
absent, and substituted by the above described sounds. 
The mechanism of these sounds is not settled. One may 
be produced at the entrance of blood into the sac, and 
the other at its exit, or the second sound may be con- 
ducted into the sac, or one may be an aortic regurgitant 
murmur. 

But any one or all of these signs may be wanting. 
Particularly is this the case where the aneurism occurs 
just after the aorta has left the heart. The most valuable 
are the pulsation, distinct and separate from that of the 
heart, and the sounds separate, and distinct from those 
of the heart, or, as graphically put by Da Costa, "two 
hearts, apparently, each with its own distinct beat, its 
own distinct sounds." * 

* Op. citat, p. 451. 



INDEX. 



ACUTE miliary tuberculosis, 72 
Adventitious sounds, 57 
^Egophony, 57 
Amphoric breathing, 53 

resonance, 39 

voice, 57 
Aneurism, thoracic, 131 
Aortic diastolic murmur, 103 

murmurs, 103 

obstruction, or stenosis, 115 

regurgitation, or incompetency, 117 

stenosis and regurgitation, 120 

systolic murmur, 103 
Apoplexy, pulmonary, 77 
Arterial murmurs, abnormal, 107 

murmurs, 107 
Asthma, spasmodic, 65 
Auscultation, 41 
Ascultation of the normal lung, 45 

Biermer's change of note, 39 
Bronchial breathing, 45 

breathing, changes in, 52 
Bronchitis, acute, 62 

capillary, 62 

chronic, 63 
Broncho-pneumonia, 76 
Bronchophony, normal, 55 
Bruit de diable, 109 

Cancer of lung, 79 
Catarrhal phthisis, 67 

pneumonia, 76 
Cavernous breathing, 52 
Chest, regions of, 11 
Cirrhosis of lung, 70 
Collapse of lung, 78 
Congenital defects of heart, 123 
Consumption, 66 
Cracked-pot sound, 41 
Crackling rales, 59 

Dilatation of the heart, 129 
Dullness, 22 

relative, of liver, 29 
Duration of percussion sounds, 27 



Emphysema, interlobular, of lung, 65 

vesicular, of lungs, 63 
Endocarditis, acute, 125 
Exocardial sounds, 104 

Fatty infiltration, 130 
Fatty metamorphosis, 130 
Fibroid phthisis, 70 
Friction sound, 60 

pleural, 60 

pericardial, 104 
Functional murmur, 105 

General considerations, 9 
Gerhardt's change of note, 38 
Gurgling, 58 

Haemic murmurs, 105 
Heart, absolute dullness of, 92 
anatomical relations of, 88 
auscultation of normal, 93 
percussion borders of, 90 
physical examination of, 88 
relative dullness of, 92 
sounds, abnormal, 99 

modifications of, 97 
impurity of, 104 
intensity of, 98 
mechanicsm of, 93 
abnormal, 99 
reduplication of, 97 
time of, 97 
Hemorrhagic infarct, 77 
Hydropericardium, 127 
Hypertrophy, general, of the heart, 129 
of the left ventricle, 127 
of the right ventricle, 128 

Inspection, 15 
Intensity of sounds, 22 

Lung, cancer of, 79 
cirrhosis of, 70 
collapse of, 78 
normal, auscultation of, 45 



135 



136 



INDEX. 



Mensuration, 15 

Metallic tinkling, 61 

Metamorphosing breath sound of 

Seitz, 54 
Mitral diastolic murmur, 102 

insufficiency, no 

insufficiency and stenosis, 115 

murmurs, 101 

obstruction, or stenosis, 113 

systolic murmur, 101 
Mucous rale, 59 
Murmurs, cardiac, 99 

functional, 99 

mitral, 101 

organic, 100 
Myocardium, diseases of, 127 
Myositis, acute, 131 

Normal breathing sounds, modifications 
of, 47 
chest, percussion of, 27 

CEdema, pulmonary, 78 

Palpation, 16 
Pectoriloquy, 56 
Percussion, 18 

auscultatory, 20 

of normal chest, 27 

respiratory, 20 

sounds, abnormal, of lung, 34 

sounds, attributes of, 21 
Pericarditis, 126 
Phthisis, catarrhal, 67 

fibroid, 70 

tubercular, 66 
Pitch of sounds, 24 
Pleurisy, acute, 79 

chronic, 83 
Pneumonia, 72 

acute croupous, 72 

catarrhal, 76 

embolic, 77 

lobar, 72 

lobular, 76 



Pneumothorax, 86 
Praecordium, 89 
Presystolic murmur, 102 
Pulmonary apoplexy, 77 

murmur, 104 

obstruction, 122 

regurgitation, 123 

Quality of sounds, 21 

Rales, 57 

dry, 58 

moist, 58 
Regions of the chest, n 
Resonance, amphoric, 39 

tympanitic, 37 

vesicular, 21 

vesiculo-tympanitic, 34 

Seitz's metamorphosing breath sound, 54 
Skoda' s sign, 36 

Tricuspid obstruction, 122 

murmur, 104 

regurgitation, 120 
Tubercular phthisis, 66 
Tuberculosis, acute miliary, 72 
Tympany, 23-39 

Valvular defects,relative frequency of,i24 

gravity of, 125 
Venous hum, 109 

murmurs, 108 
Vesicular murmur, 47 

breathing, 46 

murmur, changes in, 47 

resonance, 21 
Vesiculo-tympanitic resonance, 25, 34 
Voice, abnormal modifications of the 
auscultated, 56 

auscultation of, 54 

whispering, 55 

Wintrich's change of note, 37 
Whispering voice, 55 



